Incentivizing Long-term Recovery Through Practice & Policy

Despite improvements in the effectiveness of interventions for substance use disorders progress has been slow, particularly regarding long-term outcomes.

This editorial makes two suggestions on how to improve treatment engagement and long-term outcomes for patients….

WHAT PROBLEM DOES THIS STUDY ADDRESS?

There have been several important developments in the effort to improve treatment and long-term outcomes for substance use disorder. For example, helpful medications for alcohol use disorder and opioid use disorder are becoming more widely available. Computers (see more) and mobile technology have been used also to provide a range of interventions and services.

Despite recent developments, it is hard to conclude that major improvements in rates of sustained abstinence and recovery have been achieved. Many people with a substance use disorder are not interested in the treatments that are currently available, and receive a limited benefit in terms of long-term outcomes.

This editorial by Dr. James McKay offers insight into why limited improvements have been made in rates of sustained abstinence and recovery, and what treatment programs and policy makers can do about it.

WHAT DID THIS STUDY FIND?

McKay argues that only modest improvements have been made in terms of rates of sustained abstinence and recovery because treatments focus too much on reducing substance use & not enough on linking clients to reinforcers that will make long-term abstinence & recovery more appealing.

For example, motivational interviewing is intended to decrease ambivalence about reducing or stopping use, and cognitive behavior therapy is intended to teach the patient a skill-set to manage stressors without using alcohol or drugs. However, when the negative consequences of substance use disorder that pushed the patient into treatment begin to fade from memory, interest for most treatments is likely to fade as well without continued reinforcers for sustained recovery.

To increase rates of long-term recovery, treatments should link clients to reinforcers that will make continued abstinence more attractive & engaging.

Often, when the immediate consequences or dangers of continued use become less imminent, clients need a motivation to make the hard work of recovery more appealing. Natural reinforcers can provide sustained motivation; however, the degree to which natural reinforcers exist in an individual’s environments can widely vary.

For example, employment can provide many incentives for sustained recovery, including financial, personal meaning, social support, structure, responsibility and a sense of achievement. However, chronic unemployment is common among populations with current and past histories of substance use disorder. McKay points out that the Community Reinforcement Approach was a treatment designed to make abstinence more rewarding than use by combining cognitive behavior therapy with practical needs such as housing, couples counseling, social clubs, or sober parties.

The Community Reinforcement Approach has been shown to be more effective than contingency management (i.e., payment for sobriety) alone on a number of outcomes including number of days employed, treatment retention, less drug use, less drinking to intoxication, lower levels of depression, fewer hospitalizations and legal problems.

Local community & national policies can fill-in incentivizing gaps by creating structural supports in the environment where patients live to justify the effort needed to sustain long-term abstinence for individuals who have limited access to natural incentives.

Models that could be implemented at the community level:

The first model is a nonprofit social business enterprise which is based off a model for individuals with mental health problems called the ‘therapeutic work-place.’ In a similar vein, Jobs, Friends, and Houses is a for profit social enterprise business in England that exemplifies this model.
In the second model referred to as the ‘cooperative employer’ businesses hire individuals in recovery from substance use disorder (or support them in other ways) and require then to pass random drug tests and other types of monitoring.
Additionally, White has proposed several initiatives that range from recovery community building to reducing the hours that liquor stores and bars can serve liquor.

Models that could be implemented at the national level:

On a national level, wage supplements can be offered that are contingent on sustained abstinence.
Barriers to education should be eliminated by revoking laws that prohibit federal student loans based on prior convictions which would help foster a future orientation and reignite hope for a stimulating and rewarding future.

WHY IS THIS STUDY IMPORTANT?

The emphasis in this article on making recovery more rewarding is valuable as it stresses the need for greater attention to the positive and attractive aspects of recovery.

Most of our treatments are intended to reduce the immediate pain and suffering of active addiction but do little to increase the attractiveness of long-term remission & recovery.

Creating more natural reinforcement for recovery in workplaces, educational settings, and other community entities, could help create rewards that could be linked to maintaining a substance-free lifestyle.

Local communities and national policies can create natural reinforcers in various community entities as a way of incentivizing longer-term recoveries. Treatment providers should link clients to natural reinforcers that will make long-term abstinence more appealing.

LIMITATIONS

The most important limitation of an editorial such as this is that it represents the opinion of the author and the conclusions are typically meant to stimulate thought and debate. Also, this editorial cites empirical research when relevant to support or clarify a position to the reader, however, is not intended to be a comprehensive review of the literature.

NEXT STEPS

Currently, far more is known about factors that motivate people to quit initially, than what motivates and attracts people to engage in behaviors that help sustain recovery over time. Researchers, clinicians, family members, and policy makers can learn from the millions of individuals already in successful long-term remission what types of rewards attracted them and kept them in recovery.

These individuals possess a wealth of information on their lived experience of how to attain and maintain long-term recovery. Undoubtedly, they could describe both the dynamic and relative influence of both the negatively and positively reinforcing aspects associated with their recovery journey – the types and combinations of things made the most difference to them and at what points along the way.

BOTTOM LINE

For individuals & families seeking recovery: For some individuals initiating recovery, interest for current treatments may fade after a few months when the negative consequences that forced the person into treatment have subsided to a degree. Therefore, factors that contributed to the initiation of recovery may be slightly different than the factors that will sustain long-term recovery. Consider getting involved in recovery support services such as recovery-focused physical activity programs (e.g., Phoenix Multisport), recovery community organizations, sober cafes, recovery community centers, mutual-help organizations (e.g., NA, AA, SMART Recovery, Women For Sobriety, LifeRing, etc.), recovery high schools or collegiate recovery programs.
For Scientists: To achieve higher rates of sustained recovery, interventions and supports are needed that go beyond a focus on reducing or eliminating substance use to those that target access to opportunities that will be rewarding to individuals suffering from substance use disorder. A fruitful area of research may be to understand how other Community Reinforcement Approaches such as the development of new hobbies, recreational activities, and other involvements can help make the hard work of recovery more attractive.
For Policy makers: This editorial seeks to increase rates of treatment and long-term recovery from substance use disorder by extending the focus of interventions to include local community and national policy efforts to incentivize longer-term recoveries. Policy makers can play a pivotal role in appropriating funding for the establishment and evaluation of programs designed to increase the accessibility, attractiveness, and rewards for sustained recovery. For example, recovery community centers, sober cafes, sober physical activity organizations, freely available mutual-help resources, sober living environments, recovery high schools, and collegiate recovery programs are all a form of recovery support services. National policies can build up infrastructure by using models such as the “therapeutic workplace”, the ‘cooperative employer’, or wage supplements that are contingent upon abstinence to promote long-term recovery. Laws could also be changed to allow formerly addicted individuals the ability to apply for student loans.
For Treatment professionals and treatment systems: The helpfulness of many interventions for substance use disorder is dependent upon clients continuing to desire abstinence or reduced use. As a result, the focus is on removing something that has been of high value to the individual and little time is dedicated to increasing rewarding and enriching activities in recovery. Consider assessing the availability of natural rewards and incentives that patients may have that help sustain remission and increase the chances of long-term recovery, and facilitate linkage to community-based resources that are recovery focused, such as recovery community centers, mutual-help groups, and educational and workplace recovery support.

CITATIONS

McKay, J. R. (2016). Making the hard work of recovery more attractive for those with substance use disorders. Addiction, doi:10.1111/add.13502