After years of policy efforts focused on increasing access to evidence-based addiction treatment, less than 15% of the nearly 50 million people in the United States with an SUD receive treatment in a given year.¹ Of those, roughly 40% complete a treatment episode and 25% withdraw from treatment, and the facility terminates treatment for at least 5% of patients.^2,3

Despite low rates of treatment participation, patients are regularly dissuaded from initiating treatment until they are willing and able to commit to abstinence.^4,5 Too often patients are administratively discharged from treatment if they resume substance use.⁶ In essence, patients are denied admission or discharged from care for exhibiting symptoms of the illness for which they need treatment. These practices are inconsistent with our understanding of addiction as a chronic disease.

To address these challenges The American Society for Addiction Medicine (ASAM) developed guidance on Engagement and Retention of Nonabstinent Patients in Substance Use Treatment.⁷ Although challenges with engagement and retention of patients in SUD care have been recognized for decades, updated guidance is needed to address the deeply ingrained stigma within healthcare that impedes access to care for those who are not ready to commit to abstinence. Efforts to prevent overdose deaths will not be successful if we do not adjust our strategies to reach this population.

An expert committee, informed by a structured literature review, developed the guidance. Given the paucity of evidence in this area, the strategies primarily reflect clinical consensus. Those with more robust evidence are noted. The guidance was subject to field review and public comment before approval by ASAM’s Board of Directors. For detailed methodology, see Supplemental Materials, https://links.lww.com/JAM/A611.

RECOMMENDED STRATEGIES

Recommended strategies are summarized. For full discussion, see the full guidance document.⁷

1. 1. Cultivate patient trust by creating a welcoming, nonjudgmental, and trauma-sensitive environment. Many people who consider treatment are ambivalent about engagement. The treatment environment and atmosphere can send a powerful message to those seeking care.^8,9 At its worst, it can convey stigma, judgment, and antipathy; at its best, it can convey compassion, hope, and respect. Treatment providers can seek to:
      • Make intake and the facility environment welcoming. Avoid lengthy intake processes and create an environment that encourages patients to return.
      • Communicate with compassion and respect. Many people with SUD have had interactions with healthcare systems, including the addiction treatment system, that left them feeling stigmatized and judged. Such interactions can drive people away from care. When patients perceive that staff genuinely care about them, they are more likely to return.
      • Help patients reduce harms. Harm reduction interventions (eg, naloxone, drug checking, sterile injection supplies) convey that treatment providers:
        • ○ are realistic about the possibility of continued use,
        • ○ value the patient’s life and health, and
        • ○ have hope for the patient’s long-term outcomes.
   2. Do not require abstinence as a condition of treatment initiation or retention. For patients with SUD, abstinence from nonprescribed substances is associated with improved outcomes compared with moderation-focused approaches.¹⁰ However, when abstinence is the only available treatment goal, it can seem unreachable. Patients may view continued use or return to use as a failure instead of a chance to learn and grow. It can also be perceived as unwelcoming and judgmental, which can drive some people away from treatment.

Having goals focused on functionality or improvements in health rather than abstinence can help patients see the progress they are making through treatment, which may build confidence in their ability to take on larger goals.
Engagement of nonabstinent patients can be particularly challenging in residential settings where patients are often in a more fragile stage of illness. If a patient’s use of substances is posing a risk of harm to other patients, discharge or transition to another level of care may be appropriate.

1. 1. Optimize clinical interventions to promote patient engagement and retention. Just like the treatment environment, clinical services can convey compassion and respect. The program can focus on building strong therapeutic alliances, encouraging shared decision-making, and advocating for patients’ access to evidence-based care.

Patients and treatment providers have highlighted the importance of prioritizing support for patients’ immediate needs, such as food and shelter.^8,11 Similarly, engaging in care is challenging when you are experiencing withdrawal or know withdrawal is imminent. Prioritizing immediate needs communicates that treatment providers understand patients’ challenges; value their wellness; and see the whole person, not just the illness.
Low-threshold treatment is another evidence-based strategy for supporting engagement and creating trusting relationships with treatment providers while stabilizing symptoms and reducing risk for overdose and death.¹² Other evidence-based clinical interventions for engagement and retention include contingency management and motivational enhancement strategies.^13,14

1. 1. Only administratively discharge patients as a last resort. The perceived failure of an administrative discharge can contribute to a patient’s shame and despair. In addition, administrative discharge can lead to secondary losses (eg, employment, child custody), which can exacerbate SUD. Although administrative discharge may be necessary in some instances—such as in response to behaviors that pose a risk of harm to other patients or staff—treatment providers should minimize the practice.

Instead of discharging patients for policy infractions or disciplinary challenges, treatment providers should implement individualized and contextualized responses and proactively prevent administrative discharge whenever possible, for example, by:

1. • Training staff in de-escalation and conflict resolution
   • Establishing administrative discharge panels to implement thoughtful responses to disruptive behaviors
   • Engaging the patient’s community, including the program community and their broader support systems
2. Seek to re-engage individuals who disengage from care. Despite treatment providers’ best efforts, some patients will leave treatment or disengage after showing initial interest. Providers can seek to re-engage patients by:
   1. Following up after missed appointments
   2. Asking if the provider can do anything to keep them engaged
   3. Conveying that they are welcome to return to care when ready
3. Build connections to people with SUD who are not currently seeking treatment. Treatment providers can adopt strategies to facilitate engagement among those who are not actively seeking treatment, such as street outreach, community events, and partnerships with harm reduction organizations. Direct street outreach can reduce barriers to care and demonstrates a treatment provider’s compassion, flexibility, and willingness to “meet them where they are.”
4. Cultivate staff acceptance and support. The effectiveness of strategies 1–6 depends on staff buy-in. Staff have the power to cultivate a welcoming, nonjudgmental culture. However, patients cite judgment from or dislike of staff as a leading cause of self-discharge.⁸ This may require a culture shift, requiring leadership and staff engagement in the change process. It is important to cultivate staff support, engaging them in a discussion of the rationale, soliciting ideas for how to achieve the goal of increased engagement and retention, and providing appropriate training.
5. Prioritize retention of front-line staff. Consistent relationships with caring staff are important for building therapeutic relationships and supporting patient retention. Workforce challenges can undermine efforts to improve engagement and retention. Administrators should engage directly with staff to understand factors that influence their retention and support staff education, training, and workplace needs.
6. Align policies and procedures with the commitment to improve engagement and retention of all patients, including nonabstinent patients. Treatment providers should consider how all aspects of their service design—including policies and procedures—support or hinder engagement and retention and adjust practices to align with the strategies outlined here. Programs should strive to offer flexible appointment options to facilitate engagement, including same-day appointments, whenever possible.
7. Measure progress and strive for continuous improvement of engagement and retention. Engagement and retention are core quality metrics. Where feasible, administrators should engage staff and patient voices when planning evaluations. This reflects a program’s commitment to community engagement and shows they value lived experience, helping create feelings of inclusivity and community and supporting retention.

DISCUSSION

Promoting engagement and retention of nonabstinent patients does not mean treatment providers are enabling substance use. Rather, programs address substance use clinically, without judgment, recognizing that addiction is a chronic disease and recurrence of substance use is a common part of most patients’ course of illness.

Improving engagement and retention in SUD treatment is a multifaceted and nuanced challenge. Effective treatments are available, but they are only effective if they reach the population in need. Treatment providers must balance the needs of each patient with potential risks to other patients and staff. ASAM encourages more research to empirically test the strategies recommended here as well as approaches for retaining nonabstinent patients in more intensive levels of care while maintaining the safety of others and effectiveness of the therapeutic milieu.