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2. 2 2016 NARR Conference October 18, 2016 Boston, Massachusetts Tom Hill Senior Advisor on Addiction and Recovery Substance Abuse and Mental Health Services Administration Fitting Recovery Residences into the Current Recovery Landscape

3. 3 There’s No Place Like Home

4. 4  Mission: To reduce the impact of substance abuse and mental illness on America’s communities.  Vision: SAMHSA provides leadership and devotes its resources towards helping the nation act on the knowledge that:  Behavioral health is essential for health  Prevention works  Treatment is effective  People recover SAMHSA: A Public Health Agency within the U.S. Department of Health & Human Services

5. 5 #1- Prevention of Substance Abuse and Mental Illness #2 –Health Care and Health Systems Integration #3 –Trauma and Justice #4 – Recovery Support #5 –Health Information Technology #6 –Workforce Development SAMHSA’s 6 Strategic Initiatives

6. 6 A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. SAMHSA’s Working Definition of Recovery (SAMHSA, 2011)

7. 7 Four Dimensions of Recovery Individuals and Families HOME ↑ Permanent Housing COMMUNITY ↑ Peer/Family/ Recovery Network Supports PURPOSE ↑ Employment/ Education HEALTH ↑ Recovery Health Wellness

8. 8  Engage and promote leadership of people in recovery at all levels of State and local systems and services  Disseminate state-of-the-art information on recovery supports and services  Implement Recovery Support Action Plans for States, Territories, Tribes, and communities  Promote peer-driven, recovery-oriented systems of care BRSS TACS — Major Goals

9. 9  Policy Academies  Peer-Run Organization Subcontracts  Peer Health Reform Subcontracts  Webinars  Technical Assistance  First Fridays  Online Recovery Resource Library  Regional Summits BRSS TACS: Key Activities

10. 10  Expert Panels 3 virtual panels per year on topics related to behavioral health recovery  Webinars BRSS-TACS hosts 6 webinars per year  First Fridays A Brief Presentation and then discussion with experts on recovery topics Technical Assistance

11. 11 www.samhsa.gov/brss-tacs BRSS TACS Webpages You can find out about all BRSS TACS activities on the BRSS TACS webpages

12. 12 Today’s Talk Agenda  Setting the Context  Recovery Capital  Recovery-oriented Systems of Care  Current Events

13. 13 Setting the Context

14. 14 Addiction Recovery Advocacy Movement 2001 Recovery Summit in St. Paul  Official launch of Faces & Voices of Recovery The recovery movement:  includes people in recovery from addiction, families, and allies  includes and honors all pathways to recovery  encompasses all the diverse perspectives, cultures, and experiences of the recovery community

15. 15 You’ve seen it, right?  A feature documentary film about the over 23 million Americans living in long-term recovery from addiction to alcohol and other drugs  Released in 2013  Sparking a new conversation, following community-sponsored releases across the country  Now available on Netflix  http://manyfaces1voice.org/

16. 16 Were You There?  UNITE to Face Addiction  Rally on the National Mall, Washington, DC  October 4, 2015  http://www.facingaddiction.org/stories/

17. 17 A Perfect Storm  Recovery-oriented Systems of Care (ROSC)  Affordable Care Act  MHPAEA  Managed Care Expansion  Recovery and Family Advocacy Movements  Peer Recovery Support Services  Criminal Justice & Drug Policy Reform Movements  Opioid Public Health Crisis

18. 18 Recovery Capital

19. 19 Many Pathways of Recovery  Mutual aid  Faith-based  Treatment-supported  “Natural”  Medication-assisted  Peer support services  Combination of any of the above

20. 20 Pre- contemplation Contemplation PreparationActionMaintenance Continuum of Addiction Recovery Pre-Recovery Engagement Recovery Initiation & Stabilization Recovery Maintenance Long-term Recovery Adapted from William White Stages of Change/ Prochaska & DiClemente

21. 21 Recovery Residences in the Continuum of Recovery Long-term recovery: Independent, meaningful living in the community Service intensity Recovery process duration High Low Stabilization Acute care (inpatient, medical, psychiatric) Level 4 Level 3 Level 2 Level 1 Recovery residences: Enter at any level

22. 22 Recovery Capital is the sum of the strengths and supports – both internal and external – that are available to a person to help them initiate and sustain long-term recovery from addiction. Recovery Capital (Granfield and Cloud, 1999, 2004; White, 2006) In assisting people to achieve their recovery goals, it is often helpful to help them assess and build their Recovery Capital.

23. 23 Recovery Capital Domains DomainsKey QuestionsExamples Social What kinds of support are available from family, social networks, and community affiliations? What are the participant’s obligations to these entities?  Family and kinship networks  Friendships  Support groups  Community affiliations Physical What tangible assets (e.g., property, money, job, etc.) are available to expand the participant’s recovery options?  Money  Personal property  Job  Home Human What intangible assets (skills, aspirations, personal resources, etc.) will enable the participant to flourish in recovery?  Skills and talents  Education  Dreams and aspirations  Personal resources Cultural What network of values, principles, beliefs, and attitudes will serve to support the participant’s recovery?  Access to cultural activities  Connection to cultural institutions  Belief systems and rituals Best & Laudet (2010)

24. 24 Consequences of Addiction Can Deplete Recovery Capital  Limited education  Minimal or spotty work history  Low or no income  Criminal background  Poor rental history  Bad credit; accrued debt; back taxes  Unstable family history  Inadequate health care

25. 25 Creating and Reinforcing Recovery Capital Essential Ingredients for Sustained Recovery:  Safe and affordable place to live  Steady employment and job readiness  Education and vocational skills  Life and recovery skills  Health and wellness  Recovery support networks  Sense of belonging and purpose  Community and civic engagement

26. 26 Often, a Need to Address:  Legal issues  Criminal records  Financial status: debt, taxes, budgeting, etc.  Revoked licenses: professional, business, driver’s  Child custody  Relationship and parenting skills  Recovery support networks and community connections Creating and Reinforcing Recovery Capital

27. 27 Recovery Capital Assessment Ten Domains 1. Substance use and abstinence 2. Mental wellness and spirituality 3. Physical and medical health 4. Citizenship and community involvement 5. Meaningful activities: job/career, education, recreation, support 6. Relationships and social networks 7. Housing and safety 8. Risk taking and independence from legal responsibilities and institutions 9. Coping and life functioning 10. Recovery experience

28. 28 Recovery-oriented Systems of Care

29. 29 Service System Progression Arthur Evans

30. 30 Service System Progression Arthur Evans

31. 31 Service System Progression Arthur Evans

32. 32 A New Model Arthur Evans

33. 33 ROSC Recovery –oriented systems of care are networks of formal and informal services developed and mobilized to sustain long- term recovery for individuals and families impacted by severe substance use disorders. William White

34. 34 Focus: Recovery and Wellness Shifting from a crisis-oriented, professionally-directed, acute-care approach with an emphasis on discrete treatment episodes…. …to a person-directed, recovery management approach that provides long- term supports and recognizes the many pathways to health and wellness.

35. 35 ROSC Vision for the Long-term Th e ROSC vision is more focused on personal possibilities than pathologies and more focused on continuity of long-term support in natural community relationships than the intensity of short-term professional interventions. Evans & White, 2013

36. 36 Practice Guidelines: 10 Core Values 1Strength-Based Approaches that Promote Hope 2Community Inclusion, Partnership, and Collaboration 3Person- and Family-Directed Approaches 4Family Inclusion and Leadership 5Peer Culture, Support, and Leadership 6Person-First (Culturally Competent) Approaches 7Trauma-Informed Approaches 8Holistic Approaches toward Care 9Care for the Needs and Safety of Children and Adolescents 10Partnership and Transparency

37. 37 Three Approaches to System Transformation Additive Selective Transformational Adding peer and community-based recovery supports to the existing treatment system Practice and administrative alignment in selected parts of the system – pilot projects Cultural, values-based change drives practice, community, policy, and fiscal changes in all parts and levels of the system. Everything is viewed through the lens of and aligned with recovery- oriented care. Achara, Evans & King, 2010

38. 38 Current Events

39. 39 Consider This: The Opioid Epidemic

40. 40 Consider This: Federal Policy HHS Opioid Strategy March 2015 Three Priority Areas: 1 Provide the training, tools, and educational resources that health care professionals need to make more informed prescribing decisions. 2 Increase the use of naloxone. 3 Use medication-assisted treatment to help lift people out of opioid addiction.

41. 41 Consider This: Overdose Deaths

42. 42 Consider This: Medication Assisted Treatment

43. 43 Consider This: MAT Medication Assisted Treatment Is Here to Stay

44. 44 Consider This: Medication Assisted Recovery

45. 45 Consider This: Medication Assisted Recovery In the absence of a proactive recovery culture, the methadone maintenance patient becomes tied to an archetypal ‘spoiled identity’ to be managed and governed rather than to be retrieved, nurtured, and healed. White and Bamber (2010)

46. 46 Consider This: Medication Assisted Recovery

47. 47 Consider This: Methadone  Methadone has been used for decades to treat people who are addicted to heroin and narcotic pain medicines.  Patients taking methadone to treat opioid addiction must receive the medication under the supervision of a physician.  When taken as prescribed, it is safe and effective.  It allows people to recover from their addiction and to reclaim active and meaningful lives.  For optimal results, medication is augmented with counseling and social support. SAMHSA

48. 48 The length of time in methadone treatment varies from person to person. According to the National Institute on Drug Abuse publication, the length of methadone treatment should be a minimum of 12 months. Some patients may require treatment for years. Even if a patient feels that they are ready to stop methadone treatment, it must be stopped gradually to prevent withdrawal. Such a decision should be supervised by a doctor. Consider This: Methadone SAMHSA

49. 49 Methadone can be addictive, so it must be used exactly as prescribed. This is particularly important for patients who are allowed to take methadone at home and aren’t required to take medication under supervision at an OTP. Methadone medication is specifically tailored for the individual patient (as doses are often adjusted and readjusted) and is never to be shared with or given to others. Patients should share their complete health history with health providers to ensure the safe use of the medication. Consider This: Methadone SAMHSA

50. 50 Consider This: Buprenorphine “Buprenorphine, like methadone, when taken in stable doses as part of a medically-supervised treatment plan, permits the patient to lead a normal and productive life without any of the narcotic effects of heroin or other opioids of abuse (sic).” SAMHSA and Legal Action Center

51. 51 DATA 2000 Waiver: Buprenorphine Updates  Finalized rule: SAMHSA allows waivered physicians who qualify to treat up to 275 patients (30/100/275)  CARA extends waiver to nurse practitioners and physicians assistance  SAMHSA and ONDCP target 10 states for increased DATA 2000 waiver trainings

52. 52 Consider This: NA Methadone Policy WORLD SERVICE BOARD OF TRUSTEES BULLETIN #29 (1996) Regarding Methadone and Other Drug Replacement Programs We make a distinction between drugs used by drug replacement programs and other prescribed drugs because such drugs are prescribed specifically as addiction treatment. Our program approaches recovery from addiction through abstinence, cautioning against the substitution of one drug for another. That's our program; it's what we offer the addict who still suffers. However, we have absolutely no opinion on methadone maintenance or any other program aimed at treating addiction. Our only purpose in addressing drug replacement and its use by our members is to define abstinence for ourselves.

53. 53 Consider This: NA Methadone Policy WORLD SERVICES PAMPHLET: IN TIMES OF ILLNESS (Revised 2010) Regarding Dual Function of Methadone Sometimes, with sustained chronic pain in recovery, healthcare providers will prescribe certain medications for pain that are also used as drug replacement medications. It is important to remind ourselves that we are taking this medication as prescribed for physical pain. In this medical situation, these medications are not being used to treat addiction.

54. 54 Consider This: NA Methadone Policy WORLD SERVICES PAMPHLET: NA IN (2007) Regarding Methadone and Other Drug Replacement Programs Many addicts on drug replacement eventually do get clean, sty clean, and find a way of life they thought was unobtainable before coming to NA Some groups may decide to encourage those on drug replacement to serve as coffee or tea makers, or as a clean-up person, instead of holding leadership positions. These commitments may encourage a desire for complete abstinence through allowing these members to feel part of NA.

55. 55 The Fair Housing Act (FHA)  Protects people in MAT from housing discrimination – the same as other disabilities  Makes it illegal for recovery residences to exclude applicants based on MAT participation  Residences must grant a reasonable accommodation for persons in MAT, unless an undue burden can be proved  Applicants can be rejected based on refusal to follow non-discriminatory house rules SAMHSA and Legal Action Center

56. 56 Examples of Reasonable Accommodations  Arranging for the individual to take medication at an offsite location, when consistent with the individual’s treatment plan  Storing MAT medication in a lock box in the house and having the individual be personally responsible for it  Arranging to have the house keep and monitor MAT medications in a locked cabinet SAMHSA and Legal Action Center

57. 57 NARR Member Standards

58. 58 Oxford House Statement Regarding The Use of Methadone "Historically, Oxford House prohibited consideration of recovering individuals using Methadone. However, at its annual World Convention in Chicago in September 2010, the organization voted to restore admission discretion to the individual houses with no exclusions of any recovering individual. Each Oxford House requires an admission application, an interview by existing house members, and an 80% approval vote. This process assures that new admissions are likely to receive good recovery support from all residents already living in the house."

59. 59 Sample: Oxford House Expectations

60. 60 For Future Discussion  What questions do we need to formulate and ask of ourselves and of our communities?  What education do we need to provide for our constituents and stakeholders?  What policies and procedures do we need to revisit and possibly reconsider as we evolve and adapt to our changing world?

61. 61 A Renewed Vision  Recovery Works  Recovery is Possible  Recovery is an Expectation!