1. The Future of Addiction Treatment & Recovery in America IAODAPCA 2013 William L. White, MA Emeritus Senior Research Consultant Chestnut Health Systems bwhite@chestnut.org www.williamwhitepapers.com

2. Presentation Goals Review contextual changes that will influence future of addiction treatment Provide informed predictions related to future: 1) Substance use trends 2) Characteristics of Clients 3) Organization & funding of addiction treatment 4) Clinical philosophies and practices 5) Workforce changes Discuss Implications for addiction professionals

3. Perspective Professional elder (44 years work in the field across multiple roles) Long-term observer of historical cycles and new shifts that are without historical precedent Treatment/recovery historian with past work on trend projections

4. Perils of Prediction Keen awareness that most people who make predictions about the future make fools of themselves. “I think there is a market for maybe five computers.” –Thomas Watson, Chairman IBM, 1949

5. Shifting Contexts Cultural Climate Policy Climate Addiction Treatment Funding Climate

6. Importance of Recovery-specific Contexts in Next 5-10 years Growth/diversification of recovery mutual aid Cultural/political mobilization of people in recovery New recovery support institutions Emergence of recovery as a new organizing paradigm AC to RM/ROSC models of care New recovery support roles, e.g. recovery coach Emerging recovery research agenda

7. Substance Use Trend Projections Drug Specification * Evolution & cycling of drug choices * Increased potency of existing drugs * Altered & new methods of drug administration * Designer drugs & potential public health disasters from delayed effects * The challenge of drug combinations

8. Substance Use Trend Predictions Substance Specific Trends 1)Normalization of cannabis use will trigger greater focus on cannabis dependence & its treatment 2)Stimulant and hallucinogen use will rise with economic recovery; opioid addiction will continue to rise with any prolonged economic recession. 3)Great concern over tobacco-related morbidity & mortality with shift to smoking cessation in addiction treatment

9. Substance Use Trend Projections User Specification * Early age of onset * Gender equity * Co-occurring medical/psychiatric conditions * Severity/Complexity Profile: Family history, early onset; multiple drug use (tobacco), personal/historical trauma, co-morbidity, low personal/family/community recovery capital

10. Further Predictions on Characteristics of Clients Multiple drug use as near universal pattern --Implications for single pattern treatment approaches, MMT --Implications for single drug mutual aid fellowships, e.g., AA, CA --NA may be positioned for dramatic growth in the future With increased life expectancy and shorter duration of work life, pattern of late problem onset will increase and become major treatment specialty.

11. Organization of Addiction Treatment Prevention and early intervention will be increasingly pulled into educational and public health arenas. Increased service integration initiatives with mental health: 2 emerging concerns 1. Transcending history of contempt and harm in the name of help 2. Avoiding colonization through the integration process Increased integration of addiction treatment & primary health care

12. Organization of Addiction Treatment Increased movement of treatment into the community Increased linkage of treatment and systems of control (criminal justice and child welfare) Major concern with what distinguishes addiction treatment from other health and human services and how to protect that uniqueness

13. Funding of Addiction Treatment Weight of state and federal budget deficits will restrict growth and pose continued financial threats. Related $ pressure to reduce size of non-violent offender populations in prisons & burden of child placements will create expanded options/funding for community-based addiction treatment creating risk that addiction treatment will become appendance to CJ or CW system.

14. Funding of Addiction Treatment Many addiction treatment services will be mainstreamed within health care system (via health care reform) with specialized addiction treatment serving as safety net for those with most chronic, severe and complex problems.

15. Conceptual & Practice Shifts Distinction between AOD problems in community and in clinical settings Does field claim ownership of all AOD problems or only most sever/complex? Likely bifurcation of service location by low/moderate and high problem severity

16. Conceptual & Practice Shifts From pathology & intervention paradigms to recovery paradigm Shift from AC to RM/ROSC models of treatment, e.g., 5 years of post-tx recovery checkups for all persons admitted Push to move treatment into the community (“Treatment without walls”)

17. Conceptual & Practice Shifts Application of recovery concept to larger social systems Integration of clinical models and models of community development and cultural revitalization (Coyhis’ Healing Forest metaphor) Integration of recovery with prevention, early intervention and harm reduction Focus on breaking intergenerational cycles

18. Summary: Addiction Treatment and Stages of Recovery 1. Pre-recovery priming (Synergy of pain and hope) 2. Recovery initiation and stabilization 3. Transition to recovery maintenance 4. Enhanced quality of personal, family and community life in long-term recovery 5. Breaking intergenerational cycles of problem transmission

19. Predicted Workforce Changes Continued feminization of the field Special efforts to recruit men similar to that seen in teaching Special efforts will be required to address mismatch between % of addiction counselors of color and % of clients of color. Efforts to reverse 3-decade decline in recovery representation—new blending of academic and experiential knowledge

20. Workforce Predictions Rapid aging out of long-tenured leaders will create opportunity for rapid leadership advancement & rapid innovations within the field, but will also create vulnerability for colonization of field. Greater number of addiction professionals working in private practice

21. Implications for Addiction Professionals 1)Will be working in a wider variety of service settings 2)Will be providing services across a wider span of recovery stages, pre-recovery, recovery maintenance, enhanced quality of personal/family life in long-term recovery; breaking intergenerational cycles. 3)Will be pushed to extend knowledge of addiction pathologies and treatment to pathways, styles and stages of long-term recovery across diverse cultural contexts.

22. Implications for Addiction Professionals 4) Addiction professionals will be challenged to expand their knowledge of multiple pathways and styles of long-term recovery and the growing varieties of recovery support institutions. 5) Addiction professional roles will shift from expert model to partnership model. 6) The unit of service will shift beyond individual to include the family and the community.

23. Implications for Addiction Professionals 7) Some addiction professionals will specialize in recovery resource mapping and development and mobilization of community recovery capital—clinical consultant to community as a whole. 8) Addiction professionals will be challenged to redefine role in context of new recovery support institutions and roles.

24. Closing Reflection We are entering an era calling for the renewed activism of addiction professionals. “The best way to predict the future is to create it.” --Alan Kay