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• Emerges from hope and the potential for a better future

• Is person driven and requires self-responsibility, self-determination and self-direction

• Occurs via many pathways, as each individual has his or her own unique needs, strengths, preferences, goals, culture and background

• Is holistic, involving all aspects of an individual’s life

• Is supported by peers and allies who provide encouragement, reinforcement and support

• Is supported through relationships and social networks that validate and support a person’s ability to change

• Is culturally-based and reflects an individual’s values, traditions and beliefs

• Is supported by addressing trauma—an underlying contributing factor to substance use

• Involves individual, family and community strengths and responsibility

• Is based on respect and acceptance of people affected by substance use problemsa

Elements of recovery-oriented system of careb

• Person-centred

• Inclusive of family and other ally involvement

• Individualized and comprehensive services across the lifespan

• Systems anchored in the community

• Continuity of care

• Partnership-consultant relationships

• Strength-based

• Culturally responsive

• Responsiveness to personal belief systems

• Commitment to peer recovery support services

• Inclusion of the voices and experiences of recovering individuals and their families

• Integrated services

• System-wide education and training

• Ongoing monitoring and outreach

• Outcomes-driven

• Research-based

• Adequately and flexibly financed

a _{Substance Abuse and Mental Health Services Administration. “SAMHSA’s Working Definition of Recovery: 10 Guiding}

Principles of Recovery”, Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.

b _{Sheedy C.K. and Whitter M., Guiding Principles and Elements of Recovery-Oriented Systems of Care: What Do We Know}

from the Research?, HHS Publication No. (SMA) 09-4439. Rockville, MD: Center for Substance Abuse Treatment, Substance

6.5 Conceptual framework

of recovery management

Under the UNODC/WHO conceptualization of recovery management,229 _{activities offer patients}

opportunities to maintain stable relationships with the health-care system, social services and treatment facilities. Typically, counsellors coordinate case man- agement, engage patients frequently, provide positive support, encourage engagement in the community and manage stressful situations. Counsellors help to connect patients with other professionals who can help with social reintegration and refer them to social workers, psychologists, medical practitioners, repro- ductive health professionals, legal services officers and others in response to specific needs. These inter- ventions are coordinated by case managers in the context of facilitating continuing care.

Moreover, the UNODC/WHO approach230 _includes

activities that promote and strengthen internal and external resources to help affected individuals resolve problems related to substance use and manage the vulnerability to recurrence of such problems. Some of those activities are already present in the patient’s home, neighbourhood and community, while others can be developed. These activities have also been found to increase social reintegration and improve chances of stable remission and the maintenance of recovery:

• _{A supportive partner and a network of family and}

friends that can monitor the stability of recovery, abstinence from substances and compliance with treatment

• _{Meaningful work with appreciation in the work-}

place that replaces stigma and discrimination

• _{Engagement with individuals and social networks}

that share abstinence-oriented norms and support recovery goals

229 https://www.unodc.org/docs/treatment/111SUSTAINED_RECOVERY_MANAGEMENT.pdf 230 Ibid.

231 SAMHSA. Recovery Oriented Systems of Care Resource Guide. Rockville, MD: SAMHSA, September 2010.

• _{Political, humanitarian and spiritual involvement}

to provide meaning to life’s stressors and develop a stronger purpose in life

• _{Strengthening the individual’s resilience, self-}

efficacy and confidence to manage daily challenges, maintain commitment to recovery and avoid relapse

• _{Increasing social participation and integration in}

educational and vocational pursuits, including volunteering or community involvement

• _{Remediating legal and financial problems}

• _{Active involvement in self-help, religious or other}

support groups is associated with sustained recovery

6.6 The difference between

recovery-oriented systems of

care and recovery management

Having outlined the conceptual frameworks for recovery-oriented systems of care and recovery management, the following paragraphs outline the definitions of each of these two concepts.

Recovery-oriented systems of care can be defined as follows:

• _{They address the needs of the general population,}

at-risk populations, users of alcohol and drugs, individuals who are substance dependent and indi- viduals with chronic dependence.

• _{They also focus on informing, educating and}

empowering individuals and communities; provid- ing prevention, early intervention, treatment and recovery services; implementing policy and practice changes; mobilizing community partnerships; and evaluating services for systems improvement.

• _{As such, it is a broad-based strategy for organizing}

Recovery management programmes can be character- ized as follows:

• _{They are typically oriented to individuals with}

chronic substance use disorders in order to assist them in achieving long-term recovery.

• _{Activities include assertive engagement processes,}

strength-based assessments, recovery-focused and person-centred treatment, and recovery support services, training on self-care, post-treatment check-ups and the use of community resources to support sustained recovery.

• _{They incorporate peer support services.}

• _{Recovery management is a subset of the recovery-}

oriented systems of care concept.

The previously outlined UNODC/WHO conceptual discussion of recovery management also reflects this distinction through its emphasis on long-term recovery strategies and targeting the services to individuals with more complex needs and multiple treatment failures.232

6.7 Implementing recovery-

oriented systems of care

at the national level

Although somewhat different conceptually, recovery- oriented systems and recovery management pro- grammes build upon each other. The evidence supports the provision of recovery management services to individuals with more complex substance use needs within local systems of care. In the United States, a number of states, including California, Michigan, North Carolina, Texas, Vermont, Virginia and Wisconsin, are using the principles of recovery- oriented systems of care to reform their substance use treatment services.233 _{As discussed in the intro duction,}

232 United Nations Office on Drugs and Crime/World Health Organization. International Standards for the Treatment of Drug Use Disorders, March 2916, Geneva, Switzerland: United Nations Office on Drugs and Crime.

233 SAMHSA. Recovery Oriented Systems of Care Resource Guide. Rockville, MD: SAMHSA, September 2010.

treatment and recovery are not separate activities. Recovery services can be valuable in supporting and sustaining commitment to and engagement in treat- ment. Peer recovery services and other support pro- grammes should be integrated into treatment programmes. The following examples from the United States, Europe and the United Republic of Tanzania provide lessons on integrating recovery principals into substance use treatment systems. The state of Vermont, United States, has begun to formalize a recovery- oriented system of care through the devel- opment of a strategic plan, a mission statement and a system change approach called the “resiliency and recovery-oriented system of care” (RROSC). These efforts are supported by Vermont’s Blueprint for Health, which provides a parallel state-wide structure and a vehicle to more effectively manage chronic dis- eases using a public health model.  As part of this effort, Vermont has initiated telephone recovery check-ups, fostered peer support and strengthened an integrated approach to RROSC.

The concept of the recovery-oriented system of care is beginning to receive attention beyond the United States. At a United Nations General Assembly Special Session on drug demand reduction held in March 2015, representatives from EURAD, a European non- profit drug policy foundation, urged Member States to support drug demand reduction measures, includ- ing prevention, early detection, treatment, reduction of the health and social consequences, and recovery. In particular, they advocated for the development of recovery-oriented systems of care in the community. The following case study describes the development of a recovery-oriented system of care in the largely rural United Republic of Tanzania (70 per cent of the population is rural) and Zanzibar Archipelago (a semi-autonomous region of the United Republic of Tanzania).

CASE STUDY