Recovery Month: Reflections on 30 Years

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).

National Recovery Month 2019: ATTC Resources Address Treatment and Recovery in Diverse Populations


By Maureen Fitzgerald 
Great Lakes ATTC 

The Substance Abuse and Mental Health Services Administration (SAMHSA) first launched National Recovery Month in September 1989 to celebrate the millions of Americans living in recovery from substance use and mental health disorders. Over the past 30 years, National Recovery Month has promoted the message that treatment works, people do recover, and behavioral health is essential to overall health.

National Recovery Month also highlights the fact that substance use and mental health disorders affect everyone, regardless of age, race, gender, or socioeconomic status. With our increasingly complex and diverse population, providing culturally and linguistically appropriate treatment and recovery services is of vital importance.

Recognizing this, the ATTC Network Coordinating Office, regional centers, and population-specific centers have created a variety of relevant training resources. Topics covered include the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care and cultural humility. You’ll also find resources for working with African Americans, Latinx/Hispanic populations, American Indian & Alaska Native Populations, women, the LGBTQIA population, and youth.


Building Health Equity and Inclusion


All of these materials are now available for viewing and download on Building Health Equity and Inclusion, a new section of the ATTC website. This new page unites the Network’s collective expertise on culturally appropriate treatment and recovery services. Resources listed include practical tools that organizations can customize to meet the needs of a particular population or area.

New White Paper: Roadmap for Training and Technical Assistance Efforts in Substance Use Service Administration The Building Health Equity and Inclusion site features the recently published white paper, Roadmap for Training and Technical Assistance Efforts in Substance Use Service Administration: A Journey to Culturally and Linguistically Appropriate Services, which is also available in Spanish: Hoja de Ruta Para El Trabajo de Formación y Asistencia Técnica en la Administración de Servicios Para El Abuso De Sustancias. Developed by members of the ATTC Network CLAS Standards Workgroup and translated by the National Hispanic and Latino ATTC, the paper offers 7 recommendations to behavioral health and healthcare providers working to improve health and health care equity:

  1. Increase awareness and recognition of non-conscious stereotyping and prejudice toward racial and ethnic disparities in health care.
  2. Encourage full consideration of access to care.
  3. Recommend developing culturally sensitive assessment tools.
  4. Policy change.
  5. Diverse workforce.
  6. Improve efforts to conduct research with diverse populations.
  7. Increase efforts toward interprofessional collaboration in the prevention, treatment, and recovery of substance use disorders.


Updated Regularly with New Resources
Building Health Equity and Inclusion will be updated regularly with new resources developed across the Network. New this month is the Recovery Month 2019 Podcast: Recovery in African-American Communities, produced by the Great Lakes ATTC.


Related Resources from SAMHSA
In addition to the Recovery Month Toolkit, SAMHSA offers Recovery Month Promotional Materials ,which include public service announcements in English and Spanish. Other resources and information are available the SAMHSA page, Behavioral Health Equity Resources.


Does your organization serve clients from diverse populations? What resources do you find most useful in providing culturally and linguistically appropriate services? Let us know in the comment section below!

The Intersection of HIV and SUD: An Innovative Partnership to Educate and Support Two Critically Important Workforces


Beth A. Rutkowski, MPH
Co-Director, Pacific Southwest ATTC

It all started back in spring 2004, when Tom Freese and I received a request to set up a meeting with Tom Donohoe, a colleague from the UCLA Department of Family Medicine and Director of the LA Region of the HRSA-funded Pacific AIDS Education and Training Center (PAETC). We had become the administrative home of the Pacific Southwest ATTC in 2002, and many potential community partners were requesting meetings with us to see how we could collaborate and share PSATTC resources. But Tom Donohoe was different. He said he had resources (e.g., money) to share with us, and he meant it. This initial meeting marked the beginning of a 15+ year collaboration that has impacted thousands of HIV and SUD clinicians throughout Region 9 and beyond.


The partnership began with a focus on methamphetamine. Both Centers had been working independently on developing training curricula and resources on the topic, but when the PAETC received supplemental funding to work on the U.S./Mexico border, they immediately contacted us to help conduct needs assessments and deliver trainings. The first series we co-sponsored was “HIV, Methamphetamine, and Women.” Traveling and training with the PAETC and PSATTC faculty not only improved our respective knowledge of substance use disorders and HIV, but it helped us all sharpen our skills as trainers and content developers. We were cross training each other as much as the bi-national participants who came to our trainings. In addition, the four-city tour of the Border was fun. Often, the events that most shape us as trainers are learning and having fun with other content experts in our respective priority areas. One of the most impactful results of this initial project was the development of a “Methamphetamine TIP sheet” for HIV clinicians. The tip sheet has been revised a few times over the years, and is one of the most downloaded products from the AETC National Resource Center website (https://aidsetc.org/resource/tips-hiv-clinicians-working-methamphetamine-users-0).


“It’s been more than 15 years since I first met with Tom and Beth about working together. I remember thinking at the time “this is a no brainer” given the intersects of substance abuse and HIV, but I had no idea how much our collaborations would improve—and transform—our HIV work. We had already been working on HIV and Methamphetamine with some of our University experts and decided to initiate our collaboration developing HIV and Meth trainings focusing on providers serving Latinos in LA County. These trainings were well received and started our being “connected at the hip” for much of the next 15 years…I have to say if you work in an AETC and have not yet collaborated with your local ATTC, please do so, and vice versa.” ~ Tom Donohoe, August 2019


A few years after the PAETC and PSATTC initiated the U.S./Mexico Border Training Series, we were encouraged to expand our partnership to encompass the other Region 9 Federal Training Centers, including the Curry International Tuberculosis Center, California STD/HIV Prevention Training Center, and Cardea Services. The resulting product was the development and delivery of multiple one- and two-day training events focused on the treatment of HIV, STDs, TB, hepatitis C, family planning, and substance use. The events were held along the U.S./Mexico Border, as well in non-border communities such as Fresno, California. In each of these endeavors, the priority focus was on the provision of high quality, up-to-date data and best practices on how to treat people with HIV, TB, STIs, and substance use. We made a lot of amazing friends along the process, and trained hundreds of clinicians.


“Our U.S./Mexico border work has led to 15 years of very collaborative, productive, important, and fun work. Each year we continue to work with the PSATTC to continue our efforts on the border, and to develop curricula and materials that affect the epidemics throughout our region and nationally. In the next year, we will be working with the PSATTC on two new curricula: (1) HIV, MAT and Communities of Color and (2) HIV and Relapse Prevention. Having so many previous collaborations, I know these products will benefit from our joint passion to improve the lives of people we serve through training, TA, and capacity-building services. Through our collaboration with the PSATTC, I think we can make everything better.”
~ Tom Donohoe, August 2019


In 2010, our PAETC collaboration expanded even further when Tom Donohoe introduced us to his PAETC colleague Phil Meyer. Phil had a vision to use carry-over funds to support the development of two brief training curricula geared specifically towards HIV clinicians (target) and focused on the intersection of substance use disorders and HIV. Since meeting Phil nearly a decade ago, we have created nearly 20 products on a variety of topics, including, but not limited to: alcohol and HIV; cocaine, methamphetamine, and HIV; heroin, prescription opioids and HIV; HIV and psychotropics; How Change Happens; integrated treatment; marijuana and HIV; Nature of Addiction and HIV; screening, brief intervention, and referral to treatment; smoking and HIV; and substance use, HIV, and special populations (adolescents, women, older adults).


Many of these training products are available for viewing and downloading from the ATTC Product and Resource Catalog, available at: https://attcnetwork.org/centers/global-attc/products-resources-catalog. And several of the training curricula were developed into self-paced online courses available at no charge at: https://hivtrainingcdu.remote-learner.net/.


“In 2010, as the new Associate Director of the Charles Drew University site of the Pacific AIDS Education Training Center, I reached out to Tom Freese and Beth Rutkowski of UCLA’s PSATTC. As it turns out, that was one the best decisions I made in the last decade. What followed has been a nine-year collaboration, which has produced 18 HIV/Substance Use Disorder curricula with four more coming in the next year. The PSATTC has always been open and responsive to our particular needs, customizing content to our very specific target audience. The work has been challenging, rewarding, and equally important, fun. I honestly could not recommend them more.” ~Phil Meyer, LCSW, August 2019


In closing, it is safe to say that our partnership with the PAETC represents one of the most fulfilling and fun experiences of my career at UCLA. As Tom Donohoe mentioned, if you are not already partnering with your local AETC, you should be!

The Role of Spirituality and Faith in the Treatment and Healing of SUDs



Dawn Tyus, LPC, MAC, NCC
Director, Southeast ATTC

Celene Craig, MPH, MS


Over the past decade, there has been an emphasis on addressing the acute alcohol and drug addiction crisis in the United States. In 2016, more than 63,000 drug overdose deaths occurred in the U.S., a 21.5% increase from 2015. As of 2018, 20.1 million Americans age 12 or older have a substance use disorder (SUD) involving alcohol or illicit drugs. Within this estimation, 2.1 million people had an opioid use disorder (OUD), according to Substance Abuse and Mental Health Services Administration. Though it may seem that life-saving medicines and psychological interventions are important biological aspects in helping a person with a SUD, treating the inner, spiritual side of healing through recovery is also a central part of the continuum of addiction healthcare.

From 2002 to 2018, recognition has increased for evidence-based studies that focus on the importance of patient spirituality in treatment and healing of SUDs due to a mandate by the Joint Commission on Accreditation and Healthcare for the administration of a spiritual assessment by healthcare providers for patients and their families. Evidence-based studies have demonstrated the positive impact of faith on health and wellbeing — such as leading to lower levels of substance abuse and reducing the likelihood of using various drugs — in the course of a lifetime. These findings make including a body-mind-spirit integrated model of intervention essential, and indispensable in substance abuse prevention and recovery. Addiction specialists have found that 73% of addiction treatment programs in the United States include a spirituality-based element and faith-based volunteer support groups contribute up to $316.6 billion in savings to the economy every year. According to an overview of the available evidence-based studies on the effectiveness of faith-based substance use support programs, conducted by Brian and Melissa Grim in 2019, 84% of the studies show that faith is a positive factor in addiction prevention or recovery and a risk in less than 2% of the studies reviewed.

Faith-based organizations fill the gap where federal and state agencies are logistically unable to effectively and comprehensively confront the substance use epidemic. It shows that these organizations are able to reach beyond the person with a SUD and wrap support around their family and community.

“The value of faith-oriented approaches to substance abuse prevention and recovery is indisputable and the current decline in religious affiliation in the USA is not only a concern for religious organizations but constitutes a national health concern,” Grim said.

For the past 17 years, the Southeast Addiction Technology Center’s (SATTC) vision has been to transfer technology to faith leaders; increase the SUD workforce capacity within faith settings; and increase assessment, referral and engagement to care. SATTC has collaborated with communities of faith through the facilitation of conferences, learning academies, listening sessions, webinars and SUD workshops. It has been our mission to:

  • Dialogue and strengthen the substance use disorder knowledge for people working in communities of faith.
  • Teach communities of faith how to be catalyst for change in their communities.
  • Teach faith communities how to spark the conversation that “recovery is real, and treatment does work”
  • Bridge the gap between faith systems and community providers.
  • Empower faith communities to reduce the stigma associated with substance use disorders.
  • Provide measurable results for our target population.
  • Build capacity associated with substance use disorders that will aid in creating powerful and sustainable recovery ministries.
  • Promote access to services and resources that will empower communities and their partners, to create a welcoming and supportive environment.

We are committed and eager to bridge the gap between community providers and communities of faith to dispel the stigma around addiction and increase the knowledge capacity of faith leaders in the Southeast region. Through our intensive technical assistance program-development process, learning communities and trainings, we are able to equip faith leaders with the knowledge and skills to be change agents in their communities and help all people suffering with a substance use disorder.


NIATx Principle #2: Fix Key Problems (And Help the CEO Sleep at Night)

Mat Roosa, LCSW-R
NIATx Coach



The NIATx model is driven by five principles that research has shown to be the hallmarks of successful improvement projects. These five principles emerged from an analysis of decades’ worth of research that gathered data from 640 organizations in 13 industries, examining 80 factors on why certain projects fail while others succeed.

Principle 1, Understand and Involve the Customer, is the single most important action a change team can take to set up a project for success. In fact, the NIATx research analysis showed that this one principle has a greater impact on success than the other four combined. (See related blog post: Why Understanding and Involving the Customer Matters in Behavioral Health.)

Lose sight of your customer (your client), and you lose sight of success. 

Principle 2: Fix Key Problems (And Help the CEO Sleep at Night) switches the focus to leadership. If a change project is to be successful, it needs the full support of the agency’s leadership. The way to ensure that support is by addressing the problems that truly matter to the CEO.

Kim Linwood of Milwaukee learned the NIATx principles at
NIATx Change Leader Academy in Madison, WI, June 2019.

Change Project Pitfall: Lack of executive sponsorship
Often when change leaders are completing the NIATx project charter, they come to the “executive sponsor” box, and simply fill in the name of their supervisor.

Many are fond of saying that “team” is more of a verb than a noun. It is the act of “teaming” that creates results. The executive sponsor role in relation to the change team reflects this same truth. That is why we need to ask a critical follow-up question: Who is the Executive Sponsor, and what are they doing to ensure the success of the change project?

If everything is a priority…
We all know the second half of this statement: then nothing is a priority.

Executive Sponsors create and maintain priorities. One of the most powerful functions of the Executive Sponsor can be expressed in the following contrasting statements from two Executive Sponsors:

  • ES #1: “This change project is important, but make sure you keep doing everything else that we are already working on.”
  • ES #2: “This change project is important, so I am going to reassign a couple of tasks to make sure that you have the time you need for the change project to succeed.”

Strong Executive Sponsors like #2 approve the new project for takeoff, and they clear the runway to make sure that the project can pick up the speed it needs to lift off. It is critical to have the ES at the table during the formative stages of the project development to ensure adequate engagement and support. When an ES is reluctant to come to the table beyond a simple approval of the project, the Change Leader can help by reminding the ES of their critical role:

  • We need you to role model support for the change project.
  • We need you to dedicate resources to this effort.
  • We need you to remove the obstacles to our success.
  • We need you to encourage our team.

Change projects with weak executive sponsorship often fail to get off the ground. Change projects with strong executive sponsorship can soar.

About our Guest Blogger 
Mat Roosa was a founding member of NIATx and has been a NIATx coach for a wide range of projects. He works as a consultant in the areas of quality improvement, organizational development and planning, evidence-based practice implementation, and also serves as a local government planner in behavioral health in New York State. His experience includes direct clinical practice in mental health and substance use services, teaching at the undergraduate and graduate levels, and human service agency administration. 
You can reach Mat at: matroosa@gmail.com