Alcohol and drug abuse costs Americans approximately $428 billion annually. Despite this enormous cost—which, we must remember, is just the economic face of a community, family, and individually life-shattering problem—the vast majority of those with an alcohol or substance use problem do not receive treatment, and even fewer are likely to achieve long-term sobriety. In short, the existing system is characterized by inadequate access, high recidivism, and recurring treatment—at best, an ineffective and expensive revolving door. It has become increasingly clear that detoxification and treatment programs are insufficient to ensure abstinence from drugs and alcohol; for most people with substance use disorders, continued longer-term support following treatment is necessary.
When people leave formal treatment, ranging from a few days of detoxification up to perhaps several weeks at a specialized facility, they need a safe place to live and a job or someone willing to support them. Many of them have social networks of friends and family members who are abusing substances and may also be involved in illegal activities, and not surprisingly, such influences are harmful. Most will return to the same patterns that brought them into jail or treatment. What is needed is low cost but effective ways of changing the persons, places, and things that once surrounded users, replacing them with individuals who do not abuse alcohol and drugs, and who are employed in legal activities. Yet, how to affect this transformation in our substance use field is our greatest challenge, particularly in an era characterized by limited resources from local, state, and federal government.
Substance abuse treatment programs, perhaps recognizing their own limits in terms of both objectives and cost, have gradually moved to ever briefer formal programs, to be followed by “aftercare”. This kind of model arguably makes a good deal of sense: experts are indeed needed to provide the intensive medical and psychological services required in early recovery. Unfortunately, without aftercare, the majority of treatment recipients relapse; yet little or no attention is given to aftercare systems which actually meet the needs of individuals coming out of treatment. More typically, one receives little more than a referral to Alcoholics Anonymous (AA) or Narcotics Anonymous (NA). Participation in such groups can be beneficial for some, but cannot begin to address the range of issues faced by the newly sober, including employment and residence difficulties, broken social relationships, and the inevitable temptation of one’s pre-treatment associations and activities. It is thus not especially surprising that so many individuals soon return to previous habits. The revolving door keeps on revolving.
In the continuum from initial problematic behaviors to substance use disorder recovery, several key transition points appear to have significant overall leverage on outcomes. Assuming a treatment seeker is able to get into a program—no mean feat—he or she is still unlikely to end up on a path that leads to recovery. The lack of well thought-out, effective, and affordable aftercare represents both an enormous opportunity cost (especially in light of the difficulty of obtaining any kind of treatment to begin with) and a real cost to the service system. Available research (some of it conducted by our research team) has found that, indeed, effective aftercare is a a critical leverage point for improving individual recovery outcomes and reducing costs.
Community-based solutions include recovery homes, where individuals can support each other in creating new, sober lifestyles. Mutual help systems can facilitate the increase of supportive network density by affording individuals access to like-minded others who all know each other and interact regularly and intimately, and for whom personal transformation is an ongoing objective. Environmental factors are key contributors to maintaining abstinence after treatment, and the broader goal of a fundamentally different lifestyle. These factors include the amount and type of support one receives for abstinence. For example, we can learn from those settings like self-run Oxford House recovery homes, with a network of over 2,000 houses across the country. There are no professional staff in Oxford Houses; these self-help settings are thus inexpensive to develop and affordable for residents, who only need to pay about one hundred dollars a week to live in them, providing former substance abusers places to live for unlimited amounts of time, surrounded by new peer networks that do not use alcohol or illicit substances. Studies by our group and others have consistently found that individuals who participate in these types of aftercare services sustain abstinence for longer periods of time.
We need to find more systematic ways to help individuals in dealing with substance use disorders, whether they are in corporate America, in jails or prisons, or living on the streets. The answers to such questions all lie in a the comprehensive study of systems that attempt to refashion personal networks to support better opportunities for recovery. Changing social networks that are dominated by users and those engaging in illicit activities to ones that involve abstinence and legal activities is our challenge. There are multiple community-based organizations, like Oxford House, that represent system-level evolutions, and approaches could contribute to reducing health care costs by improving the effectiveness of our substance use treatment system in the United States, which could help us creatively think of ways to restructure and improve other health-oriented settings.
Featured image credit: Ismerős gyilkos: Paul at an Alcoholics Anonymous meeting by Lwp Kommunikáció. CC BY 2.0 via Flickr.