For decades, the substance use disorder treatment system has struggled with a basic question: How do we know when treatment is working? Too often, the answer has been reduced to a single measure: Is the person using alcohol or drugs? Abstinence can be an important and meaningful outcome. For many people, it is essential to sustained recovery. But abstinence alone is not the same thing as recovery. Likewise, meeting criteria for remission from a substance use disorder under the Diagnostic and Statistical Manual of Mental Disorders (DSM) is not synonymous with recovery.
If our goal is recovery, our outcome measures should actually measure recovery. That means healthcare systems, Medicaid programs, treatment providers, payers, and organizations such as the American Society of Addiction Medicine (ASAM) should look beyond whether symptoms have disappeared and begin systematically measuring whether the resources necessary to sustain recovery are actually being built.
One tool deserves serious consideration for doing exactly that: the Assessment of Recovery Capital, commonly known as the ARC or RC-36.
Abstinence Is an Outcome, but It Is Not the Whole Outcome
A person can stop using alcohol or drugs while still facing homelessness, unemployment, isolation, untreated health needs, fractured family relationships, legal problems, and a complete absence of supportive relationships. Conversely, a person receiving medication for opioid use disorder may be rebuilding family relationships, maintaining employment, improving physical and mental health, establishing stable housing, and developing a strong recovery support network. Which person has greater resources to sustain recovery over the long term? A system focused almost exclusively on substance use can miss that distinction.
Recovery is multidimensional. It involves more than the absence of a substance. It involves building the personal, family, social, community, and other resources that allow someone to sustain meaningful change. These resources are often described collectively as recovery capital.
Recovery Services Must Become Part of the Outcome Equation
This discussion has another major implication. Recovery residences, peer support, recovery community organizations, mutual-help groups, employment assistance, transportation, family support, and other recovery services have sometimes been treated as secondary to “clinical” treatment. That division makes less sense when recovery capital becomes an outcome.
If a peer specialist helps someone develop a sustainable recovery network, that is important. If a recovery residence provides stability that allows someone to rebuild employment and family relationships, that is important. If a recovery community organization connects an isolated individual with purpose, belonging, and long-term support, that is important.
These services may be directly contributing to the resources that sustain recovery. Our measurement systems should be capable of showing it.
A National Opportunity
The addiction treatment field is moving toward person-centered care, measurement-based care, value-based purchasing, and recovery-oriented systems. Those movements should converge around a simple principle: If recovery is the goal, recovery must be one of the things we measure.
Abstinence is important. Reduced substance use can be important. DSM remission is important. Retention in treatment is important. Mortality is important. Hospitalization and emergency department utilization are important. But none of these measures, standing alone, fully answers the question of whether someone is building the resources necessary for sustained recovery.
Recovery capital gives us another lens. The RC-36 offers the field an established tool with which to begin that conversation. CMS should evaluate its incorporation into Medicaid outcome measurement. ASAM should examine how standardized recovery-capital assessment can strengthen patient placement, continuing-care decisions, and connections to recovery support services. States and treatment systems should begin testing recovery-capital measurement as part of their quality-improvement strategies. And providers should start asking themselves a more demanding question than whether a patient simply completed treatment:
Did we help this person build the capital necessary to sustain recovery after treatment ends? That may ultimately be one of the most meaningful outcomes our field can measure.