The majority of substance abuse treatment programs nationally utilize a narrowly defined treatment approach that focuses on the symptoms of addiction, but too often neglects other risk factors, such as psychological distress, physical health problems, and a lack of healthy social support networks. Few facilities take into account the close relationship between clients’ physical health issues and their substance use, including the role that drugs and alcohol can play in compromising management of chronic illnesses and exacerbating symptoms. As a result, individuals in recovery typically have higher rates of physical health problems and untreated health issues than their sober peers (Clark, Samnaliev, and McGovern, 2009; Meterns et al., 2001). They are also at high risk for relapse once they leave treatment, given the number of co-occurring issues that have not been addressed. Over the past several years, the substance abuse treatment programs for women operated by Public Health Management Corporation (PHMC) have transitioned to a more comprehensive approach that recognizes the physical and social aspects of addiction, as well as the psychological aspects. PHMC’s Healthy Living Initiative (HLI) integrates nutrition, wellness, and fitness activities that are specifically geared toward helping clients develop healthy social support systems. In particular, HLI has found biking to be a unique and promising activity. By partnering with Gearing Up, a bicycling program for women in transition, PHMC has helped women to increase their sense of self-confidence and self-efficacy, improve physical health, and enhance treatment outcomes.
The Problem: The Multiple Tolls of Substance Abuse
Addiction to drugs and alcohol is highly correlated with co-occurring mental health issues, such as depression, low self-esteem, and post-traumatic stress disorder (Darke et al., 1995; Killen et al., 1995; Najavits and Lester, 2008). It also frequently contributes to co-occurring problems with physical health, notably diabetes, liver disease, hypertension, cardiopulmonary disease, and respiratory problems (Clark et al., 2009; Meterns et al., 2003). This is particularly true for women with addiction, who experience these problems more acutely and with earlier onset than men (Hyman et al., 2006; Najavits and Lester, 2008). For example, at Public Health Management Corporation’s (PHMC) substance abuse treatment programs for women, rates for obesity, hypertension, and asthma are significantly higher than in the general population.
But it doesn’t end there. Unlike most other chronic illnesses, addiction exacts an often overlooked toll that many programs are ill-equipped to help treat: a social cost. Recovery frequently requires individuals to change not just their substance-using behaviors, but also their friends, hobbies, and leisure activities. If these negative influences and social activities are not replaced, they will likely become triggers for relapse into continued drug or alcohol addiction.
A clear link has been demonstrated between substance use and the exacerbation of other chronic health problems (Clark et al., 2009; Weisner et al., 2001). Research has also documented a positive correlation between healthy support networks and sustained recovery (Jason et al., 2001; Lash et al., 2001; Laudet and White, 2010). The innovation challenge, as in so many fields, is turning concepts into fundable plans, navigating institutional hurdles, and assembling concrete interventions.
The Solution: Healthy Living Initiative
PHMC, a private nonprofit public health institute dedicated to improving the health of the community through outreach, education, research, planning, technical assistance, and direct services, has implemented a comprehensive fitness, health, and wellness program called the Healthy Living Initiative (HLI) to address the high rate of physical health problems among PHMC’s female clients, while also promoting the development of healthy social support sytems. HLI has been rolled out over the past four years at three PHMC facillities: CHANCES, an outpatient substance abuse treatment program for 100 women with children; Interim House Inc., a residential and outpatient substance abuse treatment program for 75 women (the majority of whom are referred through the criminal justice system); and Interim House West, a residential treatment program for 20 women with addiction and up to three of their children.
In an effort to respond to clients’ increasingly complex physical health needs, HLI targets high rates of cholesterol, diabetes, and hyptertension, which often accompany drug and alcohol use. One approach to address these conditions is to assertively link clients to one of several community-based primary care centers operated by PHMC or affiliated with the National Nursing Centers Consortium (also a PHMC affiliate). In some cases, the primary care centers actually offer services on-site at the treatment facilitiy. These linkages have helped clients to receive regular well and chronic care visits for themselves and their children, while also promoting increased information sharing between substance abuse treatment and primary care providers. Additionally, clients are linked to a medical home, where they can continue to receive high quality health care even after they complete substance abuse treatment.
All three facilities have also added nutrition and cooking classes, initially in collaboration with the Health Promotion Council, a PHMC affiliate that is dedicated to promoting health and preventing and managing chronic disease through community-based outreach, education, and advocacy, particularly among vulnerable populations. On-site menus at each treatment program were revamped to include more nutritious options. HLI also works in partnership with Drexel University’s Freedom from Smoking Program to help women cope with nicotine addiction.
To promote general wellness, the facilities added psycho-educational groups and adjunctive activities designed to help women develop healthy living skills, including yoga, spirituality, or mindfulness meditation groups.
In 2009, PHMC launched a more robust fitness component to complement on-site dance and aerobics classes. Interim House, Inc., began an intial collaboration with Gearing Up, a Philadelphia-based nonprofit that helps women improve their physical health, self-esteem, and support systems through cycling. The cycling initiative was then expanded to Interim House West and CHANCES in 2010. Gearing Up recognizes the strong correlation between improved physical and mental health, as documented in a growing body of research; numerous studies have shown that exercise can reduce anxiety, foster positive moods, and improve self-esteem. An increased sense of self-efficacy often accompanies mastery of a particular skill, such as bike riding. Meeting established exercise goals can boost self-confidence. Participants typically feel better about their appearance as they lose weight and improve their health.
Gearing Up clients are able to borrow a donated bicycle so that they can participate in a structured, 12-week riding program. All participants learn how to ride and receive instruction in a variety of other topics, including bike safety, urban commuting, stretching and basic fitness, and the benefits of exercise. Camaraderie is actively cultivated during group rides consisting of peers and volunteers. Participants are also able to enroll in an “Earn-a-Bike” program hosted by Neighborhood Bike Works, a nonprofit biking organization in West Philadelphia.
Most notable is the social benefit. Gearing Up helps PHMC’s clients to feel more connected to the larger community of riders. Gearing Up recently partnered with Sturdy Girls, a women’s biking club in Philadelphia and the first such club in the country, to link clients from Interim House to “bike buddies.” Participants also participated in the Bike Philly Ride in September 2010, sponsored by the Bicycle Coalition of Greater Philadelphia. By linking PHMC clients to various biking and fitness-related groups and events, Gearing Up is playing an important role in helping to promote long-term sobriety, given the clearly documented correlation between healthy support networks and sustained abstinence.
What Differentiates PHMC’s Treatment Programs
The majority of substance abuse treatment programs nationally utilize a narrowly focused approach to the treatment of addiction, which fails to take into account the range of other risk factors associated with the disease, including psychological distress, physical health problems, and the lack of a healthy support system. Further, few programs take into account the close relationship between clients’ physical health issues and their drug use, including the role that drugs and alcohol can play in compromising management of chronic illness and exacerbating symptoms. Some facilities are able to target some of these risk factors, but fewer are able to effectively address clients’ physical health needs while also linking them to healthy communities of recovery outside of the Narcotics Anonymous and Alcoholics Anonymous movement.
In contrast, PHMC’s treatment programs have transitioned to a more comprehensive approach that recognizes the physical and social aspects of addiction, as well as the psychological aspects. HLI has enabled PHMC’s treatment programs for women to more fully embrace the connection between mind and body and the important role that improved physical health plays in promoting long-term sobriety. HLI’s on-site wellness initiative has also helped participants to increase their sense of connectedness to healthy social support networks. Few other programs have capitalized on the link between fitness and wellness activities and their role in promoting social connectedness. This innovative approach—and the integration of cycling in particular—make HLI unique.
Preliminary data and anecdotal information collected in the past year have demonstrated the positive impact of HLI on participants’ lives, sobriety outcomes, and physical health status. Participants report increases in self-esteem and feelings of self-efficacy, which are often associated with achieving cycling goals that they thought were unattainable, improving general fitness, or losing weight. Further, bicycling exposes women to a constructive recreational activity that they can use as an alternative to drug use, enjoy with their children, and adopt as a primary means of transportation. Women have reported feeling “energized” and “stress free” after a long ride. Others speak about how HLI has connected them to a new community of sober riders whom they can always find and rely on. According to one participant, “Gearing Up … helped me find a whole new support group.” Others experienced a direct link between their satisfacation with biking and more healthy eating habits and their commitment to recovery, which was borne out in improved program retention rates.
Preliminary data related to physical health outcomes has also been promising. On average, women in HLI at Interim House lost up to 5 pounds over a two-month period. This outcome was particularly important for women entering treatment after spending time in prison, where the average female inmate gains between 15 and 20 pounds.
Finally, the early success of HLI and the integration of fitness and wellness programming into substance abuse treatment settings show great promise for helping to improve retention in treatment and prevent relapse, while also improving participants’ physical health. While no formal cost-effectiveness studies have been conducted, this integrated approach also has the potential to decrease costs associated with future substance abuse treatment and health care utilization.
Leslie Hurtig is Vice President for Behavioral Health Services at the Public Health Management Corporation (PHMC), a multi-service Public Health Institute in Philadelphia. Ms. Hurtig is responsible for overseeing PHMC’s network of ten behavioral health treatment, youth opportunity and recovery support programs. Carlos Hernandez is a Program Manager with the Behavioral Health Services Division at PHMC.
Clark, R. E, M. Samnaliev, and M. McGovern. (2009, January). Impact of substance disorders on medical expenditures for Medicaid beneficiaries with behavioral health disorders. Psychiatric Services, 60(1): 35-42.
Darke, S., A. Wodak, W. Hall, N. Heather, and J. Ward. (1992). Prevalence and predictors of psychopathology among opioid users. British Journal of Addiction, 87: 771-776.
Hyman, S. M., Garcia, M., and Sinha, R. (2006). Gender specific associations between types of childhood maltreatment and the onset, escalation and severity of substance abuse in cocaine dependent adults. American Journal of Drug and Alcohol Abuse, 32(4): 655-664.
Jason, L. A., M. I. Davis, J. R. Ferrari, and P. D. Bishop. (2001). Oxford House: A review of research and implications for substance abuse recovery and community research. Journal of Drug Education, 31(1): 1-27.
Killen, T. K., K. T. Brady, and A. Thevos. (1995). Addiction, severity, psychopathology, and treatment compliance in cocaine-dependent mothers. Journal of Addictive Diseases, 14: 75-84.
Lash, S. J., G. E. Petersen, E. A. O’Connor, Jr., and L. P. Lehmann. (2001). Social reinforcement of substance abuse aftercare group therapy attendance. Journal of Substance Abuse Treatment, 20: 3-8.
Laudet, A. B., and W. White. (2010). What are your priorities right now? Identifying service needs across recovery stages to inform service development. Journal of Substance Abuse Treatment, 38(1): 51-59.
Meterns, J. R., Y. W. Lu, and S. Parthaarathy, et al. (2003). Medical and psychiatric conditions of alcohol and drug treatment patients in an HMO: Comparison with matched controls. Archives of Internal Medicine, 163: 2511-2517.
Najavits, L. M., and K. M. Lester. (2008). Gender differences in cocaine dependence. Drug and Alcohol Dependence, 97(1-2), 190-194.
Weisner, C., J. Mertens, S. Parthasarathy, C. Moore, and Y. Lu. (2001, October). Integrating primary medical care with addiction treatment: A randomized controlled trial. Journal of the American Medical Association, 286(14): 1715-1723.