“Recognizing and developing effective strategies to address substance use and abuse amongst the homeless must become an increasing priority."
Introduction
There is tremendous work being done in the United States on a local, state, and federal level to address the Grand Challenge to End Homelessness. Many of the efforts are an outflow of the Federal Government’s commitment to a Housing First strategy. There is also increasing attention upon the urgent role of Substance Use Recovery in the homeless mitigation space. Substance use – along with mental illness – plays an outsized role in chronic homelessness. Recognizing and developing effective strategies to address substance use and abuse amongst the homeless must become an increasing priority.
Selected EBP
This paper has chosen the Evidence-Based Program of Substance Use Disorders Recovery with a Focus on Employment – specifically the Therapeutic Workplace program model. This EBP was selected because of there is growing interest in exploring the relationship between effective Substance Use Recovery and the positive correlation of employment. The target population for this EBT is the 20.4 million individuals 12 and older – as documented by the 2019 National Survey on Drug Use and Health - who have experienced a substance use disorder in the United States (Substance Abuse and Mental Health Services Administration, 2020). The primary social problem this EBP seeks to address is the difficulty in achieving a sustainable individual recovery from substance use disorders. This focus also has a material impact upon the Grand Challenge to End Homelessness. This is due to the significant role substance abuse plays in instigating and sustaining chronic homelessness. The main service gap that this EBP is designed to address is effective job placement and work retention for individuals in Substance Use Recovery.
Theory of Change
Evidence increasingly suggests that sustained substance abuse recovery has a positive relationship to employment (Sherba, 2018). In fact, employment is frequently reported as a top life aspiration by people in all stages of recovery. Work continues to be one of the best indicators of positive outcomes for individuals recovering from a SUD. The clinical explanation for this correlation can be found in elements of Self-determination Theory. Self-determination Theory suggests that everyone has the psychological needs of competence, autonomy, and relatedness (Deci, 2005). These defining psychological needs can often be efficiently and effectively met through productive work and employment.
Core components of the Therapeutic Workplace model include a motivational intervention that utilizes access to employment and wages to support therapeutic behavioral changes (Substance Abuse and Mental Health Services Administration, 2021). The most effective Therapeutic Workplace models integrate both education and skill-building programs. They also provide Service Integration, which would include co-locating clinical services with employment where that is possible. A multi-disciplinary team approach is a core component that encourages each team member to focus on their area of expertise. For example, employment staff can focus upon employment services, case managers can focus on social services needs that impact the client’s work, and clinicians can focus upon the individual’s substance use recovery. Long-term support is a core component that promotes the outcome of overall employment retention. This support is customized to the individual’s preferences, needs and past employment history. One of the primary goals of this long-term support is to strengthen the individual’s support network. This network can be enhanced if the individual chooses to disclose to their employer that they are in recovery for a substance use disorder. Of important note, individuals in recovery who choose to disclose their SUD have workplace protections under Title I of the Americans with Disabilities Act (Nichols, 2018).
Finally, addressing criminal justice involvement is a core component of an effective substance use recovery model focusing on employment.It is estimated that upwards of half of all individuals in the criminal justice system meet the criteria for official diagnosis of drug abuse or drug dependence (Karberg, 2002).Examples of this core component in action might be the inclusion of an “expungement specialist” on the treatment team and taking efforts to educate employers on best practices when hiring someone in recovery from SUD.
Evidence to Support
The Substance Abuse and Mental Health Services Administration commissioned a meta-analysis to study and evaluate the effectiveness of Substance Use Disorders Recovery with a Focus on Employment. An expert panel reviewed 239 published studies and articles dated 2004-present. At a minimum, the studies in the review “used at least a quasi-experimental design that included a matched-control or comparison group or a design or analysis that isolated the effects of the intervention” (Substance Abuse and Mental Health Services Administration, 2021). The meta-analysis also included seven study summaries which all showed positive outcomes. Based largely upon this Federal government-sponsored analysis, Substance Abuse Disorders Recovery with a Focus on Employment can be deemed an Evidence Based Practice with high confidence. It is also included in the United States Health and Human Services Department’s “Evidence-Based Resource Guide” Series.
Synthesis of Literature
Melvin, Koch and Davis note that a longitudinal study of Government Performance and Results Act (GPRA) data supports the theory that individuals who are employed are significantly more likely to successfully complete treatment than unemployed individuals (Melvin, 2012). This appears to be true whether the work is paid or volunteer (Aklin, 2014). Individuals who struggle with SUD are better able to maintain their long-term sobriety if they work (Duffy, 2013). The literature consistently shows that individuals with SUD who are employed are more likely to have lower rates of substance use recurrence compared to those who are unemployed. They are more likely to demonstrate higher rates of substance use abstinence than those who are unemployed. They have less criminal activity and fewer paroled violations. And they consistently demonstrate a more successful transition from residential treatment back to a normalized community life (Petry, 2014).
A survey of two Therapeutic Workplace (TW) studies sheds meaningful light on the dynamics of this EBP. Aklin, et. al., studied eight-year outcomes of a social business intervention. Individuals were randomly assigned to a TW or standard care. All participants were unemployed and had at least one urine positive for opioids or cocaine in the six weeks prior to study enrollment. The participants were 83% African American and 17% White. Only 10% were employed full-time in the past 3 years. Of the 20 individuals who were randomly assigned to TW, 9 effectively transitioned from training to employment. At the 5–8-year post-induction follow up, the average monthly income of the TW group was $1,086 compared to $622 for the standard care group (Aklin W. M., 2014).
In study two, Holtyn, et. al., conducted a randomized control trial of a Therapeutic Workplace program designed to promote treatment engagement and abstinence for injection-drug users who were currently out of treatment. Participants were all individuals with an Opioid Use Disorder. The participants were 69% African American and 30% White. Recruitment participants were encouraged to enroll in a Methadone treatment program and were offered non-contingent access to a TW. After 26 weeks, 80% were participating in Methadone treatment, and 70% at the six-month follow-up (Holtyn, 2014).
There are challenges to employment for individuals with SUD, however. Statistically, those with SUD have - on average - a lower education level and often have a lack of basic job skills. Many have a criminal history. Employers also often have a poor understanding of SUD and there are frequent reports of schedule conflicts with probation and treatment requirements (Chintakrindi, 2015). To address these challenges, it is recommended that employers consider recovery-friendly employment policies. These policies might include creating an intentional company culture that recognizes the realities of substance use and abuse and places a spotlight on recovery options and wellness. Employers should also consider providing supportive intervention policies such as allowing an employee to take a personal leave of absence to seek treatment and use personal sick leave to attend recovery groups when necessary. Private employers are not legally required to have a drug-free work policy. However, there is a movement underway that emphasizes a “recovery-friendly” workplace. New Hampshire, for example, is one of at least five states that have started statewide initiatives to encourage businesses to employ people in recovery.
There are limitations to this specific field of study. Evidence-based research that focuses on recovery is still regarded as limited. Many of the studies that do exist have short follow-up timelines of just 1-2 years. In contrast, a plethora of recovery studies suggest that the difficulties of maintaining sobriety changes across time and are different at distinct life stages (Margolis, 2000). There are also questions about whether predictors of short-term substance abstinence also hold accurate for long-term recovery.
Other research challenges include both variations in population and variations in programs studied. There are often co-occurring disorders amongst those with SUD. These disorders might include physical illness, mental illness, PTSD, and traumatic brain injuries. Many also have criminal justice issues and experience chronic homelessness. In short, it can be difficult to establish a study group with similar enough issues to produce reliable data. And programs can differ enough to be hard to accurately compare efficacy. Program duration and medical dosage differences across studies can present a research challenge.
Conclusion
The data supporting the Evidence-based Practice of Substance Use Recovery with a Focus on Employment is compelling. It is noteworthy that this EBP addresses the physical, sociological, and economic well-being of the individual in a holistic fashion. As previously recognized, the three key factors of Self-determination Theory are all positively enhanced by this EBT – competence, autonomy, and relatedness. This suggests that this EBT is a uniquely efficient program or practice with the capacity to provide substance use disorder recovery help, economic support, personal meaning, and community connectivity all at once. This fact underscores the importance of this approach in a comprehensive system to address substance use disorders and help alleviate chronic homelessness.
References
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Substance Abuse and Mental Health Services Administration. (2021). Substance Use Disorders Recovery with a Focus on Employment. Washington, DC: U.S. Department of Health and Human Services.
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