Who this is for
Adults in early recovery from any SUD. Active withdrawal requiring medical management is stabilized clinically before pathway start. MAT (Suboxone, naltrexone, etc.) coordinated with prescriber, not replaced. Severe co-occurring SMI co-managed with psychiatry.
What brings people here
Post-IOP / inpatient referral; AUDIT >=8; DAST >=3; self-referral; HR referral; PCP referral after MAT initiation.
Clinical framework
OneVillage-developed (SAMHSA outcomes framework).
How the 8 weeks run
Baseline assessments, your first SMART goal, and the 1:1 that sets up everything after it.
Specialist coaches rotate in, and sessions come thickest here. One change at a time, in the domains your baseline flagged.
Re-score, refresh the care plan, and check in 1:1 on what is and is not working.
The remaining domains, at a lighter cadence, and the work of making the early weeks hold under pressure.
Final re-score, relapse prevention, and the plan for what happens next.
When your sessions fall
The program is built in four-week modules. Sessions come thickest at the start, when what you decide matters most, and step down as things settle. That is 5 sessions of 45 minutes across 8 weeks, counting the visit before week 1.
| Module | Weeks | Sessions | Cadence |
|---|---|---|---|
| Module 1 | Weeks 1 to 4 | 2 | every other week |
| Module 2 | Weeks 5 to 8 | 2 | every other week |
Week by week
- Before you beginBefore you begin
This is the reading before your first visit. It is written for adults in recovery from any substance use disorder, at any stage, including people who are still using and people who have relapsed and come back. Nothing in this program requires you to be doing well to qualify for it.
- Week 1Medication for addiction treatment
If you take one week of this program seriously, take this one. Medication for addiction treatment outperforms everything else measured in this field, including everything in this pathway.
- Week 2Sleep in early recovery
This week you meet Kelly Day O'Brien, NBC-HWC, the Sleep Coach, for 45 minutes. Sleep is the complaint we hear most in early recovery and the one most often dismissed as something to wait out. It is worth treating in its own right, and there is evidence that it is not merely uncomfortable.
- Week 3Naloxone, and staying alive
This week is about not dying while the rest of the work happens. That is a blunt way to put it and it is the accurate one. Everything else in this program depends on you being here for it, and the measures that keep people alive are cheap, legal and under-used.
- Week 4Mid-program, and what relapse actually is
Week 4 is your second 45-minute visit with Cindy and a repeat of the week 0 measures. It is also where we say plainly what this program thinks about relapse, because that belief determines whether you tell anyone when it happens, and telling someone is what makes it survivable.
- Week 5Other people
Isolation is one of the most reliable features of the weeks before a return to use, and connection is one of the few protective factors that costs nothing. This week is about the options, described accurately, including the ones this program does not require you to like.
- Week 6Stress, and what reinforces a habit
This week you meet Christine Squires, the Stress Coach, for 45 minutes. Stress is the precipitant people name most often when they map a return to use, and it is also the area where the advice on offer is at its vaguest. This week tries to be specific about what has actually been tested.
- Week 7Work, money and the rest of a life
By this stage, most of the work is no longer about substances. It is about a life with enough structure, income and purpose in it that recovery has somewhere to live. This week covers the practical pieces, and the parts of it that this program can actually take off your hands.
- Week 8Making it hold
Week 8 is your third 45-minute visit with Cindy and the last of the scheduled program. This pathway runs for at least twelve months, so week 8 is a checkpoint rather than an ending.
Who you will work with
Your Whole Health Coach takes your first visit and closes every module, so it is the same person from the first session to the last. The specialists below lead the weeks where their work is the focus.
Professionally, Cindy has been a clinical nurse for nearly a decade. She served in both clinical and administrative capacities throughout her career and holds a Master's degree in Nursing Leadership. As a staff nurse, nurse leader, and quality improvement specialist, she led multidisciplinary teams in academic medical settings throughout Boston, New York, and Ohio to deliver high-quality care to patients across complex diagnoses.
Kelly is a sleep behavior expert who connects to clients with genuine curiosity and compassion to unlock their potential for positive change. Sleep is a universal need AND is completely unique to the individual. No two sleep profiles are the same and Kelly uses multi-faceted and science-based approaches to support an understanding of the client’s desired outcome.
Are you ready to take control of your stress and embrace a more fulfilling life? Meet Christine, a dedicated stress management coach with over a decade of experience helping individuals navigate life’s challenges. Since 2011, she has worked in various addiction and mental health settings, equipping clients with effective tools to manage stress, overcome crises, and cultivate resilience.
What we work on
| Domain | What this pathway does |
|---|---|
| Nutrition & Metabolism | Nutrition repair in early recovery: protein, B-vitamins, omega-3, hydration. Sugar/caffeine moderation. |
| Movement & Mobility | Movement as mood regulation. Build a routine that's not gym-dependent. |
| Sleep & Recovery | Sleep destroyed in active use; restoration takes 3-12 months. ISI tracked. No alcohol-as-sleep. |
| Stress & Resilience | Stress is the #1 relapse trigger. Daily relaxation; sponsor/peer call as tool. |
| Mind & Mood | Depression/anxiety prevalence very high in recovery. PHQ-9 + GAD-7 monthly. |
| Relationships & Purpose | Relational repair is core. Peer connection is protective. |
How progress is measured
These are the validated tools this pathway uses: at your first visit, at the mid-program review, and at the end.
| Tool | Cadence | Owned by |
|---|---|---|
| AUDIT / DAST-10 | Onboard, quarterly | WHC; LCSW reads |
| SOCRATES (stage of change) | Onboard, PRN | WHC |
| Brief Addiction Monitor (BAM) | Every 2 weeks | WHC + LCSW |
| PHQ-9 + GAD-7 + C-SSRS | Onboard, monthly; PRN safety | LCSW |
| ISI | Onboard, q4 weeks | Sleep Coach |
| Peer / mutual-help engagement log | Weekly | Peer Recovery |
The research behind this pathway
Your clinician playbook was built from the guidelines and studies below. They are listed so you can read them yourself: every one is a real, published paper and the number at the end of each line is its PubMed ID.
Guidelines this pathway follows
- SAMHSA recovery outcomes framework · Substance Abuse and Mental Health Services Administration
Recovery defined across health, home, purpose and community, not abstinence alone.
- Medication for addiction treatment · Cochrane and AHRQ reviews
This pathway supports medication rather than treating it as a failure. PMID 24825644
- Continuing care · McKay review
Long, low-intensity contact is what the evidence supports, and it is what this pathway's later modules are. PMID 33500871
Key studies
- Bush K et al. (1998). Arch Intern MedThe AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test
Introduced the three-question AUDIT-C, which is the drinking screen used here and the reason the first conversation is short. PMID 9738608
- Mattick RP et al. (2014). Cochrane Database Syst RevBuprenorphine maintenance versus placebo or methadone maintenance for opioid dependence
Cochrane's review across 31 trials and 5,430 people. Buprenorphine keeps people in treatment better than placebo at any dose above 2 mg, and suppresses illicit opioid use at 16 mg or more. PMID 24500948
- Jonas DE et al. (2014). JAMAPharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis
Pooled the outpatient trials of medication for alcohol use disorder. Naltrexone and acamprosate both reduced drinking, and this pathway supports medication rather than treating it as a failure. PMID 24825644
- Kelly JF et al. (2020). Alcohol AlcoholAlcoholics Anonymous and 12-Step Facilitation Treatments for Alcohol Use Disorder: A Distillation of a 2020 Cochrane Review for Clinicians and Policy Makers
The Cochrane review of Alcoholics Anonymous and 12-step facilitation across 27 studies and 10,565 people, distilled for clinicians: as good as other established treatments on most outcomes, better on continuous abstinence, and cheaper. PMID 32628263
- McKay JR (2021). Alcohol ResImpact of Continuing Care on Recovery From Substance Use Disorder
Reviewed continuing care for substance use disorder. Pooled effects were small, but continuing care of longer duration with active effort to keep people engaged produced more consistent results. That is the shape of this pathway's later modules. PMID 33500871
- Prendergast M et al. (2006). AddictionContingency management for treatment of substance use disorders: a meta-analysis
Pooled 47 comparisons of contingency management. Rewarding the behavior you want is one of the more reliable levers in this field. PMID 17034434