In 1968, Martin Luther King, Jr. said “One of the great liabilities of history is that all too many people fail to remain awake through great periods of social change. Every society has its protectors of status quo and its fraternities of the indifferent who are notorious for sleeping through revolutions. Today, our very survival depends on our ability to stay awake, to adjust to new ideas, to remain vigilant and to face the challenge of change” (Boren & Perkins, 1999). With that quote, I would like to present this article, which focuses on the future of addictions treatment in America. Its goal is to stimulate thought and hopefully inspire preparation for the future, so that addictions professionals can “stay awake” and “not fall asleep” through the addiction and behavioral health revolution. In this article, predictions will be made about the future of addictions treatment in America. It begins on a precautionary note: Most people who make predictions about the future make fools of themselves. For example, in the 1940s IBM Chairman Thomas Watson stated, “I think there is a world market for maybe five computers” (Carr, 2008). These predictions will focus on a number of categories: organizational health, where services take place, substance use trends, client characteristics, future funding of addictions treatment, clinical shifts, and workforce changes.
In the future, we will put as much energy into staff appreciation, organization, and team health as we extend to the health of our clients.
There are myriad rewards that come from working in the addictions field, including witnessing the miracle of recovery, seeing families rebuilt, and long-term relationships with colleagues in the field. At the same time, there are a number of challenges.
A study by McLellan, Carise, and Kleber found that 50 percent of addictions counselors and administrators leave their jobs within a year of being hired (2003). Knudsen, Johnson, and Roman’s research reveals that the average turnover rate of addictions professionals far exceeds the national turnover rates across all occupations and is nearly twice as high as other helping professions, including teaching and nursing (2003). In an article entitled “The Toughest Job You’ll Ever Love,” Gallon and colleagues stated that turnover in the addictions field leads to organizational instability and decreased effectiveness in client care (2003). Contributing factors to turnover include:
- High rates of burnout and compassion fatigue (White, 1997)
- Dysfunctional organizational dynamics (O’Connell et al., 2007)
- A poorly trained and prepared workforce (Gallon, Gabriel, & Knudsen, 2003)
- Tension in the supervisor-counselor relationship (Sanders, 2011)
- The absence of human resources departments that could be instrumental in meeting the needs of employees (O’Connell et al., 2007)
- Recovering professionals treated as marginal in the field, which often includes lower pay, the absence of a voice, and the lack of opportunity for advancement (White, 2009)
- Low pay
Unless there is a focus on organizational health, it will be difficult to successfully implement evidence-based practices in the future. It takes five years to develop world-class expertise in any field (Gladwell, 2008), including the mastery of an evidence-based practice. Our current rate of staff turnover falls far beneath this five-year mark.
Where Services Take Place
We will begin to move toward treatment without walls. Seventy-five percent of chemically dependent clients will never get help directly for their addictions. They will end up in hospitals, prisons, mental health facilities, child welfare agencies, etc. Methamphetamine use is a major epidemic in rural America; yet, meth users constitute only four percent of treatment admissions (Sanders, 2011).
If, in the future, clients will not come in, we will go out and get them. The role of the recovery coach will be greatly elevated, as community outreach will be an important part of addiction recovery. Many chemically dependent clients live in communities that are high risk for relapse. These communities often have high unemployment rates, family disintegration, heavy substance use, and apathy. To address this, we will begin to see the entire community as the treatment center. This will lead to more nontraditional affiliations within the community. Addictions treatment programs will begin to align with community colleges and vocational schools; churches, mosques, and synagogues; indigenous healers, including tribal chiefs, medicine men, and monks; primary care physicians, to monitor clients for medical conditions caused by their addictions; and employers, to provide jobs for individuals in recovery.
We will reconnect and strengthen our relationship with the Twelve Step community. With the rise of cocaine use in the mid-1980s, many addiction treatment programs became major profit centers. Some became so busy making money that they lost their connection with the Twelve Step community. Today, as I travel the country doing presentations, I often ask participants, “How many of you work in a program that has a Twelve Step meeting on the premises?” Fewer than 10 percent raise their hands. Forty years ago, the great majority of addictions treatment agencies had Twelve Step programs on the premises.
This reconnection will be necessary in order to create a seamless system of care, from treatment into communities of recovery. Narcotics Anonymous will be particularly important in supporting recovery, since the majority of clients with substance use disorders utilize more than one drug.
Substance Use Trends
Drug use patterns continue to change. They continue to cycle among three categories:
- Socially celebrated drug. These are drugs used societies in which one could not imagine a celebration without. In America the celebrated drug is alcohol.
- Socially tolerated drugs. These are drugs such as medical marijuana and cigarettes. Society says you can use these drugs under a doctor’s supervision or in a certain location.
- Socially prohibited drugs. These drugs carry the strongest legal sanctions and stigma in society (White, 1997). They include methamphetamines, crack cocaine, and heroin.
It is not uncommon for drugs to shift from one category to the next, based upon society’s reactions to the consequences of the use of the drug and the demographics to which the drug is linked. For instance, in the 1970s, cocaine in powder form was considered a socially celebrated drug used by the affluent. By the mid-1980s, the drug shifted to a socially prohibited drug when a primary method of use was smoking in the form of crack and linked to people in communities of color. At the turn of the twentieth century, heroin was considered a socially celebrated drug, used medicinally. Following the deaths of many adolescents, the drug shifted from celebrated to prohibited by passage of the Harrison Act (Kinney, 2003). Today, it has reached the prohibited status again, as there are many overdoses reported nationwide. In the future, addictions professionals will need to pay attention to the rise and fall of the status of drugs, because this can influence the nature of what clients are treated for.
We will continue to see challenges that occur when a combination of drugs are taken together. We will discover which drugs are lethal if taken in combination with other drugs. We will see the normalization of cannabis use as a result of legalization in several states and the increased movement to further legalize the substance in other states. More clients will think, “If it is legal, how can it be a problem?” I think our position on this in the future should be that alcohol is legal, and there is a certain percentage of the population who cannot drink because of the consequences that come with drinking, and there are also individuals who have major problems connected to marijuana use who should consider not using even if it is legal.
We can expect to see a rise in stimulant and opiate use during future prolonged economic recessions, as individuals in communities most affected numb themselves to deal with this challenge. There will be a greater concern with tobacco-related morbidity and mortality, as nicotine kills more people than alcohol, all illicit drugs, and HIV combined, increases relapse rates, triggers a return to alcohol use for clients who typically drink and smoke cigarettes at the same time, and can trigger a return to heroin, methamphetamines, crack or marijuana use. Additionally, lighting a match to smoke a cigarette can trigger a craving for other drugs that also require the lighting of a match (Sanders, 2011). To meet this challenge, the addictions field will shift toward adding smoking cessation to their addictions treatment programs.
Prediction of Client Characteristics
We will witness an earlier onset of substance use, which will require counselors to be skilled at working with younger clients. Another prediction is that increasing numbers of girls and women will enter treatment systems as clients, requiring agencies to become increasingly gender-responsive and trauma-informed. We will also need to possess skills to treat co-occurring, medical, and psychiatric conditions, and multiple drug use will be the universal pattern. Increased life expectancy will create a generation of older adults who did not become vulnerable to addiction until after retirement. To address this, addictions professionals will need increased knowledge of how to work with older adults.
We will focus more attention on longer-term monitoring. Eighty percent of chemically dependent clients relapse within the first ninety days of treatment. Some of the highest recovery rates on record are doctors and pilots who are monitored for five years after a treatment episode—the risk of relapse after five years of sobriety drops to beneath 15 percent (Sanders, 2011).
We will begin to accept multiple pathways of recovery. This shift has already begun. There are recovery high schools, recovery coaches, recovery basketball teams, recovery track teams, recovery drop-in centers, recovery industries, and recovery drug ministries. This will require the field to have an open mind to the range of ways that clients recover. We will increasingly address chemical addiction and process addictions under the same roof. Many clients go back and forth between chemical addiction, sexual addiction, eating disorders, compulsive gambling, compulsive spending, and internet addiction without these various addictions ever being addressed in treatment. Increased service integration is necessary, as addiction and mental health overlap at the rate of 50 percent (Mueser, Noordsy, Drake, & Fox, 2003).
There will be increased integration of addictions treatment and primary health care. This movement is already underway because of the new health care initiatives. This will require addictions professionals to be bilingual; they will have to have the ability to speak both the addiction and medical languages. They will need to be able to protect the very elements that distinguish addictions treatment from other health and human services, namely the peer, wounded healer, spiritual components, and service work.
Funding of Addictions Treatment
State and federal deficits will continue to be a threat, requiring the field to identify nontraditional sources of financial support. We will need to do research that supports the cost effectiveness of treatment and recovery. We will hold our own town hall meetings with political candidates prior to elections and will support those candidates who support addictions treatment and recovery. We will have a recovery ribbon; whenever medical conditions have ribbons, whether it is breast cancer or HIV, this is a visible sign that the stigma of the medical condition is decreasing. When stigma decreases, there is increased giving by philanthropists and everyday citizens to the cause. In order to decrease the stigma of addictions further, we will need to continue to have recovery month celebrations and more people of prominence in long-term recovery publicly telling their stories.
There will be pressure to reduce the size of nonviolent prison populations, as prison stays are costly for states. This reduction will create new funding options for community-based addiction treatment programs.
Predicted Workforce Changes
We will see a feminization of the field. Disproportionately students in undergraduate and graduate counseling and social work programs are women. To create gender balance we may see in the future special efforts to recruit men as counselors, similar to efforts to recruit men as teachers in elementary and high schools.
There will also be special efforts to address the mismatch between the percentage of counselors of color and clients of color. Research indicates that counselors are increasingly younger, white, and female, and clients are increasingly younger, of color, and male (O’Connell, 2007). This trend may require us to be sure that the future workforce is prepared to do effective cross-cultural counseling. Emphasis will be placed on rectifying three decades of decline of recovery representation of staff and ensuring that the recovering voice is heard in the treatment process.
Another prediction is that we will experience a leadership void in the addictions and behavioral health fields, as retirement of long-tenured leaders will create opportunities for a new generation of leaders. To address this, the addictions field should begin to do mentoring and training to prepare the next generation of leaders. We will see a greater number of addictions professionals working in private practice, as there is an increase in the requirement of licensure, and new health care initiatives will add millions of individuals to the insured rolls who will have private insurance covering treatment for substance use disorders. Some professionals will work as consultants to entire communities, tribes, and villages, shifting the intervention from the micro to the macro level.
There is a famous saying, “The future belongs to those who prepare for it today.” The hope is that individuals and organizations that provide addictions treatment and recovery support will begin to think about the future, prepare for it, and take the lead to create it.
Acknowledgements: I would like to acknowledge the writings and lectures of William L. White, MA, as a major inspiration for this article.
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