Challenges in going from residential substance abuse treatment to the community

"According to SAMHSA (2015), alcohol and drug abuse and related problems contribute substantially to the burden of disease in the U.S., costing an estimated $400 billion annually," said Dr. Jennifer Manuel, PhD, an assistant professor at the NYU Silver School of Social Work, and an affiliated researcher with New York University's Center for Drug Use and HIV Research (NYU CDUHR). "It is essential to reduce the cycle of treatment for SUDs -- both for public health and financial reasons."

Long-term residential substance abuse treatment is a preferred option for those seeking to recover from SUDs. "In-patient" treatment provides intensive recovery-related services combined with safe housing and assistance with daily living. However, relapse following discharge is still common and can reverse or deplete improvements made during treatment. According to the statistics, the rates of relapse within the first year after discharge range from 37% to 56%.

Engagement in aftercare services has been shown to improve this statistic. However research shows that only about half of patients make initial contact with outpatient care, and very few complete recommended duration of aftercare services.

In order to explore the factors that hinder and help individuals transition from long-term residential substance abuse treatment centers to the community, Dr. Manuel and her collaborators, Dr. Obie Nichols and Ms. Erin Palmer, from Services for the UnderServed, Inc., (SUS) conducted a qualitative socio-ecological model-based study, "Barriers and Facilitators to Successful Transition from Long-Term Residential Substance Abuse Treatment," the findings of which were recently presented at the 2016 Alcoholism and Substance Abuse Providers of New York State conference.

The research team focused on five barrier/facilitator categories: individual, interpersonal, organizational, community, and policy. The study is published on-line ahead of print in the Journal of Substance Abuse Treatment, December 2016.

"We know little about the transition barriers and facilitators from long-term residential substance abuse treatment from the perspectives of individuals with SUDs," notes Dr. Manuel. "Using the socio-ecological model as a guiding framework, this study explores the individual, interpersonal, organizational, community, and policy factors that impede and facilitate the transition from residential substance abuse treatment from the perspectives of individuals with SUDs who are anticipating discharge from treatment."

The study consisted of semi-structured interviews (45-90 minutes in length) with individuals (n=32) from a long-term residential substance abuse treatment program (average length of stay is 6 months) in NYC. Interviews were digitally recorded and subsequently transcribed. Individuals received a $30 gift card for participating in the interview. Participants ranged in age 23-55 years old; over three-fourths of the participants were male. All but one participant was receiving Medicaid benefits, with 56% of participants having been mandated to treatment. Nearly all (90.6%) participants reported being jailed or incarcerated in their lifetime; three-fourths reported being homeless in their lifetime.

Common barriers to successful transition:

• The researchers noted that unmet basic needs, like financial stability, a job, and a place to live showed up as a primary individual barrier (in 62.5% of respondents).
• Many participants expressed having limited to no support network (46.9%), strained relationships (43.8%), and friends who use drugs (40.6%) as interpersonal barriers.
• One common organizational barrier was having a staff shortage in the residential treatment programs (34.4%). There were few challenges related to transition at community and policy levels; however, what did come up was returning to stressful neighborhoods (31.3%) and lack of housing available for people with only substance use problems (34.4%).

"What these results show is that the primary areas of intervention needed for these individuals include access to stable housing and employment, aftercare services and positive support networks; expanded discharge planning services and transitional assistance, and funding to address gaps in service delivery and meet individuals' basic needs," said Dr. Manuel "These findings suggest the importance of both informal and formal supports to reinforce and continue progress made in residential treatment."

The researchers' findings from this study suggest that transitions from residential treatment are stressful, particularly as people balance competing priorities of meeting their basic needs with managing their addiction. Enhanced support post-discharge from residential treatment is critical to improve the quality of transitions and outcomes of individuals with substance use disorders.

This study is the first phase of a larger initiative to develop and pilot test Critical Time Intervention, a transitional assistance model for individuals leaving residential substance abuse treatment. The study's findings are based on data that were generated from a small, non-probability sample of mostly male individuals from a single long-term residential substance abuse treatment program, and thus are not representative of other individuals in long-term residential treatment programs and their experiences.

Nevertheless, the results identify key factors to consider during the transition from long-term residential treatment to the community, and the findings from this study will inform future intervention development that aims to significantly improve mid-range and long-term outcomes among people with SUDs leaving residential treatment.