Recovery Management: Recovery Management: Changes in Clinical Changes in Clinical

Practices Practices

William L. White, M.A.William L. White, M.A.

Sr. Research Consultant Sr. Research Consultant

Chestnut Health SystemsChestnut Health Systems

Presentation Goal Presentation Goal

Outline how frontline service practices Outline how frontline service practices are changing in traditional addiction are changing in traditional addiction treatment programs that are moving treatment programs that are moving from an acute care (AC) model of from an acute care (AC) model of intervention to a model of sustained intervention to a model of sustained recovery management (RM)recovery management (RM)

Based on Experience with RM Based on Experience with RM Pilot SitesPilot Sites

• RM-related Research Sites (e.g., CHS, RM-related Research Sites (e.g., CHS, NDRI)NDRI)

• RM consultations (e.g., IL, CT, AZ, RM consultations (e.g., IL, CT, AZ, Philadelphia)Philadelphia)

• Training and consultation with RCSP Training and consultation with RCSP and ATR service sites and ATR service sites

Two Central QuestionsTwo Central Questions

1. How would we treat addiction if we 1. How would we treat addiction if we reallyreally believed that addiction was a believed that addiction was a chronic disease?chronic disease?

2. How would we treat addiction if we 2. How would we treat addiction if we were only paid for successful were only paid for successful recovery outcomes?recovery outcomes?

The Acute Care ModelThe Acute Care Model

• An encapsulated set of specialized service An encapsulated set of specialized service activities (assess, admit, treat, discharge, activities (assess, admit, treat, discharge, terminate the service relationship).terminate the service relationship).

• A professional expert drives the process.A professional expert drives the process.• Services transpire over a short (and ever-Services transpire over a short (and ever-

shorter) period of time.shorter) period of time.• Individual/family/community is given Individual/family/community is given

impression at discharge (“graduation”) impression at discharge (“graduation”) that recovery is now self-sustainable that recovery is now self-sustainable without ongoing professional assistance. without ongoing professional assistance.

Treatment (Acute Care Treatment (Acute Care Model) Works! Model) Works! Post-Tx remissions one-third, AOD use Post-Tx remissions one-third, AOD use

decreases by 87% following Tx, & decreases by 87% following Tx, & substance-related problems decrease substance-related problems decrease by 60% following Tx (Miller, et al, by 60% following Tx (Miller, et al, 2001).2001).

Lives of individuals and families Lives of individuals and families transformed by addiction treatment. transformed by addiction treatment.

Treatment Works, BUT…Treatment Works, BUT…

AC & RM Model Review AC & RM Model Review

Comparison on 10 key dimensions of Comparison on 10 key dimensions of service design and performance: service design and performance: The who, what, where, when and The who, what, where, when and how of service delivery how of service delivery

• AC Model VulnerabilityAC Model Vulnerability

• RM Model Strategy to Address that RM Model Strategy to Address that VulnerabilityVulnerability

1. AC Model Vulnerability: 1. AC Model Vulnerability: AttractionAttraction

Only 10% of those needing treatment Only 10% of those needing treatment received it in 2002 (Substance received it in 2002 (Substance Abuse and Mental Health Services Abuse and Mental Health Services Administration, 2003); only 25% will Administration, 2003); only 25% will receive such services in their lifetime receive such services in their lifetime (Dawson, et al, 2005). (Dawson, et al, 2005).

Why People Who Need it Don’t Why People Who Need it Don’t Seek TreatmentSeek Treatment• Perception of the Problem: My problem Perception of the Problem: My problem

isn’t that bad.isn’t that bad.• Perception of Self: I can and should handle Perception of Self: I can and should handle

this without outside help.this without outside help.• Perception of Treatment: Perception of Perception of Treatment: Perception of

treatment as ineffective, unaffordable, treatment as ineffective, unaffordable, inaccessible and “for losers”inaccessible and “for losers”

• Perception of others: Fear of stigma and Perception of others: Fear of stigma and discriminationdiscrimination

Source: Cunningham, et, al, 1993; Grant 1997 Source: Cunningham, et, al, 1993; Grant 1997

Coercion vs. Choice Coercion vs. Choice

The majority of people who do enter The majority of people who do enter treatment do so at late stages of treatment do so at late stages of problem development and under problem development and under external coercion (SAMHSA, 2002).external coercion (SAMHSA, 2002).

The AC model does not voluntarily The AC model does not voluntarily attract the majority of individuals attract the majority of individuals who meet diagnostic criteria for a who meet diagnostic criteria for a substance use disorder. substance use disorder.

RM Model Strategy: RM Model Strategy: AttractionAttraction• Local anti-stigma campaigns, e.g., Recovery Local anti-stigma campaigns, e.g., Recovery

is Everywhere Campaign in Ann Arbor, MIis Everywhere Campaign in Ann Arbor, MI• Recovery-focused community education Recovery-focused community education • Population-based early screening Population-based early screening • Assertive models of community outreach Assertive models of community outreach • Non-stigmatized service sites, e.g., Non-stigmatized service sites, e.g.,

hospitals & health clinics, workplace, hospitals & health clinics, workplace, schools, community centersschools, community centers

Principle: Earlier the screening, diagnosis & Principle: Earlier the screening, diagnosis & Tx, the better the prognosis for long-term Tx, the better the prognosis for long-term recoveryrecovery

2. AC Model Vulnerability:2. AC Model Vulnerability:Access & EngagementAccess & Engagement

Access to treatment is compromised Access to treatment is compromised by waiting lists (Little Hoover by waiting lists (Little Hoover Commission, 2003).Commission, 2003).

High waiting list dropout rates (25-High waiting list dropout rates (25-50%) (Hser, et al, 1998; Donovan et 50%) (Hser, et al, 1998; Donovan et al, 2001). al, 2001).

Substantial obstacles to treatment Substantial obstacles to treatment access for some populations (e.g., access for some populations (e.g., women) (White & Hennessey, 2007)women) (White & Hennessey, 2007)

Weak Engagement & Weak Engagement & Attrition Attrition Dropout rates between the call for an Dropout rates between the call for an

appointment at an addiction treatment agency appointment at an addiction treatment agency and the first treatment session range from 50-and the first treatment session range from 50-64% (Gottheil, Sterling & Weinstein, 1997),64% (Gottheil, Sterling & Weinstein, 1997),

Nationally, more than half of clients admitted to Nationally, more than half of clients admitted to addiction treatment do not successfully addiction treatment do not successfully complete treatment (48% “complete”; 29% complete treatment (48% “complete”; 29% leave against staff advice; 12% are leave against staff advice; 12% are administratively discharged for various administratively discharged for various infractions; 11% are transferred) infractions; 11% are transferred) (OAS/SAMHSA 2005) (OAS/SAMHSA 2005)

High Extrusion as a High Extrusion as a Motivational FilterMotivational Filter

High AMA and AD rates constitute a form of High AMA and AD rates constitute a form of “creaming” e.g., view that “Those who “creaming” e.g., view that “Those who reallyreally want it will stay.” want it will stay.”

The reality: those least likely to complete The reality: those least likely to complete are not those who want it the least, but are not those who want it the least, but those who need it the most—those with those who need it the most—those with the most severe & complex problems and the most severe & complex problems and the most severely disrupted lives (Stark, the most severely disrupted lives (Stark, 1992; Meier et al, 2006).1992; Meier et al, 2006).

RM Model Strategy:RM Model Strategy:

• Assertive waiting list managementAssertive waiting list management• Streamlined intakeStreamlined intake• Lowered thresholds of engagement Lowered thresholds of engagement • Pain-based (push force) to hope-based (pull-Pain-based (push force) to hope-based (pull-

force) motivational strategiesforce) motivational strategies• Appointment prompts & phone follow-up of Appointment prompts & phone follow-up of

missed appointmentsmissed appointments• Institutional outreach for regular re-motivationInstitutional outreach for regular re-motivation• Radically altered AD polices (White, et al, Radically altered AD polices (White, et al,

2005)2005)

Altered View of Motivation Altered View of Motivation

Motivation seen as important, but as an Motivation seen as important, but as an outcome of a service process, not a pre-outcome of a service process, not a pre-condition for entry into treatment. A strong condition for entry into treatment. A strong therapeutic relationship can overcome low therapeutic relationship can overcome low motivation for treatment and recovery motivation for treatment and recovery (Ilgen, et al, 2006). (Ilgen, et al, 2006).

Motivation for change no longer seen as sole Motivation for change no longer seen as sole province of individual, but as a shared province of individual, but as a shared responsibility with the treatment team, responsibility with the treatment team, family and community institutions (White, family and community institutions (White, Boyle & Loveland, 2003).Boyle & Loveland, 2003).

3. AC Model Vulnerability: 3. AC Model Vulnerability: Assessment & Tx Planning Assessment & Tx Planning

• CategoricalCategorical

• Pathology-focused, e.g., problem list Pathology-focused, e.g., problem list to treatment plan to treatment plan

• Unit of assessment is the individualUnit of assessment is the individual

• Professionally-drivenProfessionally-driven

• Intake function Intake function

RM Model Strategy: RM Model Strategy: Assessment & Recovery Assessment & Recovery Planning Planning • Global rather than categorical (e.g., ASI, Global rather than categorical (e.g., ASI,

GAIN)GAIN)• Strengths-based (emphasis on assessment of Strengths-based (emphasis on assessment of

recovery capital) (Granfield & Cloud, 1999)recovery capital) (Granfield & Cloud, 1999)• Greater emphasis on self-assessment versus Greater emphasis on self-assessment versus

professional diagnosis professional diagnosis • Unit of assessment is individual, family and Unit of assessment is individual, family and

recovery environmentrecovery environment• Continual rather than intake activityContinual rather than intake activity• Rapid transition to recovery plans (Borkman, Rapid transition to recovery plans (Borkman,

1998) 1998)

4. AC Model Vulnerability: 4. AC Model Vulnerability: Service Elements Service Elements

• Widespread use of approaches that lack Widespread use of approaches that lack scientific evidence for their efficacy and scientific evidence for their efficacy and effectiveness (in spite of recent effectiveness (in spite of recent advances)advances)

• Minimal individualization of care, e.g., Minimal individualization of care, e.g., reliance on going through the “program”reliance on going through the “program”

• Only superficial responsiveness to special Only superficial responsiveness to special needs, e.g., specialty appendages rather needs, e.g., specialty appendages rather than system-wide changesthan system-wide changes

RM Model Strategy: RM Model Strategy: Service ElementsService Elements

• Emphasis on evidence-based, evidence-Emphasis on evidence-based, evidence-informed & promising practicesinformed & promising practices

• High degree of individualization, e.g. from High degree of individualization, e.g. from programs to service menus whose elements programs to service menus whose elements are uniquely combined, sequenced & are uniquely combined, sequenced & supplementedsupplemented

• Emphasis on mainstream services that are Emphasis on mainstream services that are gender-specific, culturally competent, gender-specific, culturally competent, developmental appropriate, and trauma-developmental appropriate, and trauma-informed informed

5. AC Model Vulnerability: 5. AC Model Vulnerability: Composition of Service Team Composition of Service Team

AC Model often uses medical (disease) AC Model often uses medical (disease) metaphors but utilizes a service metaphors but utilizes a service team made up almost exclusively of team made up almost exclusively of non-medical personnel.non-medical personnel.

AC model uses a recovery rhetoric but AC model uses a recovery rhetoric but representation of recovering people representation of recovering people in Tx milieu via staff and volunteers in Tx milieu via staff and volunteers has declined via professionalization.has declined via professionalization.

RM Model Strategy:RM Model Strategy: Composition of Service Team Composition of Service Team

• Increased involvement of primary care Increased involvement of primary care physicianphysician

• New service roles, e.g., recovery coachesNew service roles, e.g., recovery coaches• Utilization of new service organizations, e.g. Utilization of new service organizations, e.g.

community recovery centers (White & Kurtz, community recovery centers (White & Kurtz, 2006) 2006)

• Renewed emphasis on recovery-based Renewed emphasis on recovery-based volunteer programs and alumni associationsvolunteer programs and alumni associations

• Inclusions of “indigenous healers” in Inclusions of “indigenous healers” in multidisciplinary team, e.g., faith communitymultidisciplinary team, e.g., faith community

6. AC Model Vulnerability: 6. AC Model Vulnerability: Locus of Service Delivery Locus of Service Delivery

• Institution-basedInstitution-based

• Weak understanding of physical and Weak understanding of physical and cultural contexts in which people are cultural contexts in which people are attempting to initiate recoveryattempting to initiate recovery

• AC Model question: “How do we get AC Model question: “How do we get the individual into treatment”--get the individual into treatment”--get them from their world to our world?them from their world to our world?

RM Strategy:RM Strategy:Locus of Service DeliveryLocus of Service Delivery

• Home-, neighborhood- & community-Home-, neighborhood- & community-based based

• RM question: “How do we nest RM question: “How do we nest recovery in the natural environment recovery in the natural environment of this individual or create an of this individual or create an alternative recovery-conducive alternative recovery-conducive environment?”environment?”

• ““Healing Forest” metaphor; concept Healing Forest” metaphor; concept of treating the communityof treating the community

7. AC Model Vulnerability: 7. AC Model Vulnerability: Service Dose and Duration Service Dose and Duration

One of the best predictors of treatment One of the best predictors of treatment outcome is service dose. Many of outcome is service dose. Many of those who complete treatment those who complete treatment receive less than the optimum dose receive less than the optimum dose of treatment recommended by the of treatment recommended by the National Institute on Drug Abuse National Institute on Drug Abuse (National Institute on Drug Abuse, (National Institute on Drug Abuse, 1999; SAMHSA, 2002)1999; SAMHSA, 2002)

AC Model Vulnerability: AC Model Vulnerability: Discharge, Abandonment, Discharge, Abandonment, Relapse, Re-admissionRelapse, Re-admission

The majority of people completing addiction The majority of people completing addiction treatment resume AOD use in the year treatment resume AOD use in the year following treatment (Wilbourne & Miller, 2002). following treatment (Wilbourne & Miller, 2002).

Of those who consume alcohol and other drugs Of those who consume alcohol and other drugs following discharge from addiction treatment, following discharge from addiction treatment, 80% do so within 90 days of discharge 80% do so within 90 days of discharge (Hubbard, Flynn, Craddock, & Fletcher, 2001). (Hubbard, Flynn, Craddock, & Fletcher, 2001).

  

AC Model Vulnerability: Failure AC Model Vulnerability: Failure to Manage to Manage Addiction/Tx/Recovery CareersAddiction/Tx/Recovery CareersMost persons treated for substance Most persons treated for substance

dependence who achieve a year of dependence who achieve a year of stable recovery do so after multiple stable recovery do so after multiple episodes of treatment over a span of episodes of treatment over a span of years (Anglin, Hser, & Grella, 1997; years (Anglin, Hser, & Grella, 1997; Dennis, Scott, & Hristova, 2002).Dennis, Scott, & Hristova, 2002).

Fragility of Early Recovery Fragility of Early Recovery

Individuals leaving addiction treatment are Individuals leaving addiction treatment are fragilely balanced between recovery and fragilely balanced between recovery and re-addiction in the hours, days, weeks, re-addiction in the hours, days, weeks, months, and years following discharge months, and years following discharge ((Scott, Foss, & Dennis, 2005)Scott, Foss, & Dennis, 2005)..

Recovery and re-addiction decisions are Recovery and re-addiction decisions are being made at a time that we have being made at a time that we have disengaged from their lives, but that many disengaged from their lives, but that many sources of recovery sabotage are present. sources of recovery sabotage are present.

AC Model Vulnerability: AC Model Vulnerability: Clinical AbandonmentClinical Abandonment

Durability of alcoholism recovery (the point Durability of alcoholism recovery (the point at which risk of future lifetime relapse at which risk of future lifetime relapse drops below 15%) is not reached until 4-5 drops below 15%) is not reached until 4-5 years of remission (Jin, et al, 1998). years of remission (Jin, et al, 1998).

20-25% of narcotic addicts who achieve 20-25% of narcotic addicts who achieve five or more years of abstinence later five or more years of abstinence later return to opiate use (Simpson & Marsh, return to opiate use (Simpson & Marsh, 1986; Hser, Hoffman, Grella, & Anglin, 1986; Hser, Hoffman, Grella, & Anglin, 2001). 2001).

Fragility of Family RecoveryFragility of Family Recovery

““While recovery alleviates many of the family’s While recovery alleviates many of the family’s historical problems, this early period can also historical problems, this early period can also be referred to as the “trauma of recovery”: a be referred to as the “trauma of recovery”: a time of great change, uncertainty and time of great change, uncertainty and turmoil.”turmoil.”

““The unsafe, potentially out-of-control The unsafe, potentially out-of-control environment continues as the context for environment continues as the context for family life into the transition and early family life into the transition and early recovery stages...as long as 3-5 years.” recovery stages...as long as 3-5 years.”

Source: Brown & Lewis, 1999Source: Brown & Lewis, 1999

AC Model Vulnerability: AC Model Vulnerability: “Aftercare” as an Afterthought “Aftercare” as an Afterthought

Post-discharge continuing care can enhance Post-discharge continuing care can enhance recovery outcomes (Johnson & Herringer, recovery outcomes (Johnson & Herringer, 1993; Godley, et al, 2001; Dennis, et al, 1993; Godley, et al, 2001; Dennis, et al, 2003).2003).

But only 1 in 5 (McKay, 2001) to 1 in 10 But only 1 in 5 (McKay, 2001) to 1 in 10 (OAS, SAMHSA, 2005) adult clients receive (OAS, SAMHSA, 2005) adult clients receive such care (McKay, 2001) and only 36% of such care (McKay, 2001) and only 36% of adolescents received adolescents received anyany continuing care continuing care (Godley,et al, 2001) (Godley,et al, 2001)

AC Treatment as the New AC Treatment as the New Revolving Door Revolving Door

Of those admitted to the U.S. public Of those admitted to the U.S. public treatment system in 2003, 64% were re-treatment system in 2003, 64% were re-entering treatment including 23% entering treatment including 23% accessing treatment the second time, 22% accessing treatment the second time, 22% for the third or fourth time, and 19% for the for the third or fourth time, and 19% for the fifth or more time (OAS/SAMHSA, 2005). fifth or more time (OAS/SAMHSA, 2005).

RM Model Strategy: Assertive RM Model Strategy: Assertive Approaches to Continuing CareApproaches to Continuing Care• Post-treatment monitoring & support Post-treatment monitoring & support

(recovery checkups)(recovery checkups)• Stage-appropriate recovery education & Stage-appropriate recovery education &

coachingcoaching• Assertive linkage to communities of recoveryAssertive linkage to communities of recovery• If & when needed, early re-intervention & re-If & when needed, early re-intervention & re-

linkage to Tx and recovery support groups linkage to Tx and recovery support groups • Focus not on service episode but managing Focus not on service episode but managing

the course of the disorder to achieve lasting the course of the disorder to achieve lasting recovery.recovery.

RM Model Strategy: RM Model Strategy: Assertive Approaches to Assertive Approaches to Continuing CareContinuing Care1. Provided to all clients not just those 1. Provided to all clients not just those

who “graduate”who “graduate”

2. Responsibility for contact: Shifts 2. Responsibility for contact: Shifts from client to the treatment from client to the treatment organization/professional organization/professional

RM Model Strategy: RM Model Strategy: Assertive Approaches to Assertive Approaches to Continuing CareContinuing Care3. Timing: Capitalizes on critical 3. Timing: Capitalizes on critical

windows of vulnerability (first 30-90 windows of vulnerability (first 30-90 days following Tx) and power of days following Tx) and power of sustained monitoring (Recovery sustained monitoring (Recovery Checkups) Checkups)

4. Intensity: Ability to individualize 4. Intensity: Ability to individualize frequency and intensity of contact frequency and intensity of contact based on clinical databased on clinical data

RM Model Strategy: RM Model Strategy: Assertive Approaches to Assertive Approaches to Continuing CareContinuing Care5. Duration: Continuity of contact over time 5. Duration: Continuity of contact over time

with a primary recovery support specialistwith a primary recovery support specialist6. Location: Community-based versus 6. Location: Community-based versus

clinic-basedclinic-based7. Staffing: May be provided in a 7. Staffing: May be provided in a

professional or peer-based delivery formatprofessional or peer-based delivery format8. Technology: Increased use of telephone- 8. Technology: Increased use of telephone-

& Internet-based support services& Internet-based support services

8. AC Model Vulnerability: 8. AC Model Vulnerability: Relationship with Recovery Relationship with Recovery Communities Communities Participation in peer-based recovery support Participation in peer-based recovery support

groups (AA/NA, etc.) is associated with groups (AA/NA, etc.) is associated with improved recovery outcomes (Humphreys et improved recovery outcomes (Humphreys et al, 2004). al, 2004).

This finding is offset by low Tx to community This finding is offset by low Tx to community affiliation rates and high (35-68%) attrition in affiliation rates and high (35-68%) attrition in participation rates in the year following participation rates in the year following discharge (Makela, et al, 1996; Emrick, 1989) discharge (Makela, et al, 1996; Emrick, 1989)

Passive/active LinkagePassive/active Linkage

Active linkage (direct connection to Active linkage (direct connection to mutual aid during treatment) can mutual aid during treatment) can increase affiliation rates (Weiss, et al increase affiliation rates (Weiss, et al 2000),2000),

But studies reveal most referrals from But studies reveal most referrals from treatment to mutual aid are passive treatment to mutual aid are passive variety (verbal suggestion only) variety (verbal suggestion only) (Humphreys, et al 2004) (Humphreys, et al 2004)

RM Model StrategyRM Model Strategy

• Staff & volunteers knowledgeable of Staff & volunteers knowledgeable of multiple pathways/styles of long-term multiple pathways/styles of long-term recovery and local recovery community recovery and local recovery community resources and Online recovery support resources and Online recovery support meetings and related servicesmeetings and related services(White & Kurtz, 2006)(White & Kurtz, 2006)

• Direct relationship with H & I committees Direct relationship with H & I committees and comparable service structuresand comparable service structures

• Recovery coaches provide assertive Recovery coaches provide assertive linkages to support groups and larger linkages to support groups and larger communities of recoverycommunities of recovery

9. AC Model: 9. AC Model: Service RelationshipService Relationship

Dominator-Expert Model: Recovery Dominator-Expert Model: Recovery is based on relationships that are is based on relationships that are hierarchical, time-limited, transient hierarchical, time-limited, transient (via frequent transition of client (via frequent transition of client from one worker to the next as from one worker to the next as well as problems of staff turnover) well as problems of staff turnover) and commercialized.and commercialized.

RM Model:RM Model:Service RelationshipService Relationship

Partnership Model: Recovery is based on Partnership Model: Recovery is based on imbedding the client/family in recovery imbedding the client/family in recovery supportive relationships that are natural, supportive relationships that are natural, reciprocal, enduring, and non-reciprocal, enduring, and non-commercialized.commercialized.

Vision is continuity of contact in recovery Vision is continuity of contact in recovery support relationship over time.support relationship over time.

--Will require stabilization of field’s --Will require stabilization of field’s workforceworkforce

10. AC Model Vulnerability:10. AC Model Vulnerability:EvaluationEvaluation

Focus on professional review of short-Focus on professional review of short-term outcomes of single episodes of term outcomes of single episodes of care and short-term effects of care and short-term effects of interventions on social coast factors, interventions on social coast factors, e.g. hospitalizations, arrests, e.g. hospitalizations, arrests, employment, welfare status, etc.employment, welfare status, etc.

Tx-outcome studies problem- rather than Tx-outcome studies problem- rather than solution-focused; we are just beginning solution-focused; we are just beginning to learn about long-term recovery.to learn about long-term recovery.

RM Model Strategy:RM Model Strategy:Evaluation Evaluation

• Focus on effect of interventions on Focus on effect of interventions on addiction/treatment/recovery careersaddiction/treatment/recovery careers

• Greater involvement of clients, families & Greater involvement of clients, families & community elders in design, conduct and community elders in design, conduct and interpretation of outcome studies. interpretation of outcome studies.

• Search for potent service combinations Search for potent service combinations and sequencesand sequences

• Need for recovery research agenda to Need for recovery research agenda to support evolution of RM modelsupport evolution of RM model

Closing ThoughtsClosing Thoughts

1. RM represents not a refinement of 1. RM represents not a refinement of modern addiction treatment, but a modern addiction treatment, but a fundamental redesign of such fundamental redesign of such treatment.treatment.

2. Overselling what the AC model can 2. Overselling what the AC model can achieve to policy makers and the public achieve to policy makers and the public risks a backlash and the revocation of risks a backlash and the revocation of addiction treatment’s probationary addiction treatment’s probationary status as a cultural institution. status as a cultural institution.

Closing ThoughtsClosing Thoughts

3. It will take years to transform 3. It will take years to transform addiction treatment from an AC addiction treatment from an AC model of intervention to a RM model model of intervention to a RM model of sustained recovery support.of sustained recovery support.

4. The transition to a RM model is 4. The transition to a RM model is crucial if we are to protect the future crucial if we are to protect the future of addiction treatment and recovery of addiction treatment and recovery in America.in America.