Welcome to the November edition of Tips and Topics.

In SAVVY and SKILLS, pay attention to the services, systems, policies and staff that can advance ten recommendations from a paper “Clinical Considerations for Engagement and Retention of Nonabstinent Patients in Care” published in the latest edition of the Journal of Addiction Medicine.

In SOUL, when I looked at the speakers’ list for an upcoming conference at which I had previously presented a keynote, there was a momentary tinge of nostalgia for those speaking days. But with papers like the one in this month’s Tips and Topics, I am reassured that the younger generation has “got this.”  What I long advocated for in addiction treatment systems is in good hands.

I have long advocated for addiction treatment systems:

• To move away from program-driven, abstinence-mandated treatment to person-centered, outcomes-driven, individualized treatment.

• To offer services that clinically apply what Alcoholics Anonymous (AA) calls “attraction, not promotion” and encourage members to “keep coming back.”

• To meet people with addiction where they are at in their stage of change and skillfully evoke from them reasons to consider and hopefully be attracted to embrace recovery.

• To develop services that keep clients coming back, retained in treatment and in a Discovery process if they are not yet ready for a Recovery journey. It is hard to help a person if they have dropped out or don’t feel welcomed and understood.

• To craft policies and procedures that treat slips, lapses and relapses as learning opportunities for those struggling with addiction, rather than to punish them and “kick them out.”

So I was encouraged when I saw the following paper in the latest edition of the Journal of Addiction Medicine: Clinical Considerations for Engagement and Retention of Nonabstinent Patients in Care. You can read and even download the paper if you want. But in this month’s edition I will summarize the 10 recommended strategies (not necessarily in order). All the content is from the paper that I have organized in the Tips and Topics format under my summary TIPS.

References:

Boyle MP, Gibson E, Lien J, Manages S, Mohr S, Ryan C, Tsai G. Clinical Considerations for Engagement and Retention of Nonabstinent Patients in Care. J Addict Med. 2025 Sep-Oct 01;19(5):504-506. 

Tip 1

Create services and systems that are person-centered and welcoming.

Recommendation No. 1: Cultivate patient trust by creating a welcoming, nonjudgmental, and trauma-sensitive environment.

The paper provides reasons for this recommendation:

• “Many people who consider treatment are ambivalent about engagement.”

• “The treatment environment and atmosphere can send a powerful message to those seeking care… it can convey compassion, hope, and respect.”

The recommended SKILLS are:

• “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.”

• “When patients perceive that staff genuinely care about them, they are more likely to return.”

• “Help patients reduce harms. Harm reduction interventions (e.g., naloxone, drug checking, sterile injection supplies) help 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.”

Recommendation No. 3: 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.”

Tip 2

Review your policies and procedures to check that they support and advance engagement and retention, not dropout.

Recommendation No. 2:  Do not require abstinence as a condition of treatment initiation or retention.

• “For patients with Substance Use Disorder (SUD), abstinence from nonprescribed substances is associated with improved outcomes compared with moderation-focused approaches.”

• “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.” 

Recommendation No. 4:  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 (e.g., 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.”

“Proactively prevent administrative discharge whenever possible, for example, by:

• 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.” 

Recommendation No. 9:  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.”

Tip 3

Build services and systems that attract people who have disengaged from care or aren’t even currently seeking treatment.

Recommendation No. 5:  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:

• Following up after missed appointments.

• Asking if the provider can do anything to keep them engaged.

• Conveying that they are welcome to return to care when ready.”

Recommendation No. 6:  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.’”

Tip 4

Focus on building the understanding, support and retention of staff who are ready for a culture shift towards engagement and retention.

Recommendation No. 7: 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.

• 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.”

Recommendation No. 8:  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.”

Tip 5

Track progress in engagement and retention and commit to continuous quality improvement.

Recommendation No. 10:  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.”

SOUL

I still get emails about upcoming conferences. I recently looked at the speakers’ list for a conference that was one of the last few conferences at which I was a keynote presenter. For a couple of seconds, there was a tinge of nostalgia for the satisfaction I got from speaking – trying to inspire and attract attendees into shifting their thinking and skills towards person-centered services.

I often wondered how many of the attendees actually changed their clinical behavior and attitudes.  The science of Adult Learning depressingly shows that didactic sessions and lectures are generally ineffective at producing significant or lasting behavior change.

If you add methods like hands-on problem-solving; coaching and guided instruction with feedback; and experiential learning activities, you can see actual behavior change.

Now don’t get me wrong, those few seconds of nostalgia didn’t push me back into the mentoring, coaching, training and consulting ring. When I read papers like the one in this month’s Tips and Topics, I rest easy that the younger generation has “got this.” 

I can go back to focusing on the important decisions like: Which new culture will I travel to next?  Will I go by car, boat or plane? 

What I long advocated for in addiction treatment systems is in good hands.

UNTIL NEXT TIME

Thank you for joining us this month. See you in December.

David