Tracking functional recovery in a community-based substance use disorder program: a five-year descriptive evaluation using the brief addiction monitor

TL;DR

A community-based substance use disorder program in Florida used a five-year evaluation to track recovery progress using a functional assessment tool.

Contribution

The study demonstrates the effectiveness of a low-barrier, integrated care model in supporting recovery from substance use disorders.

Findings

Substance use and risk scores decreased while protective factors increased over five years.

Opiate use and reported overdose history significantly declined among participants.

Patient satisfaction improved with more participants reporting extreme satisfaction.

Abstract

Accessible, evidence-based treatment for substance use disorders (SUDs) remain a public health challenge due to complex clinical and social needs and barriers to long-term engagement. This study describes a five-year evaluation of a low-barrier, outpatient SUD treatment program implemented by the Health Care District of Palm Beach County, Florida, focusing on trends in functional recovery using the Brief Addiction Monitor (BAM) functional assessment.

Between February 2018 to March 2023, participants with substance use disorders received care through a Federally Qualified Healthcare Center (FQHC) based integrated model offering medication for opioid use disorder, other Medication assisted treatment, behavioral health services, medical , psychiatric, peer services, and care coordination. The BAM was administered at baseline and approximately every three months to assess substance use, risk, and protective factors. Data were analyzed per assessment to reflect variability in patient engagement and follow-up.

A total of 2,425 patients completed 5,277 BAM assessments. Among those with repeated assessments (n = 982), the average substance use score declined from 5.19 to 3.45, while the risk score dropped from 14.61 to 11.01. Protective scores increased from 10.65 to 12.40. Reported opiate use decreased from 26.1% at baseline to 17.3% at follow-up. Self-reported overdose history declined from 38.6% to 17.5% (added in 2021). Patient satisfaction improved, with “extremely satisfied” responses rising from 21.6% to 36.5%.

This descriptive evaluation highlights the potential of low-threshold, integrated care models to support recovery-oriented outcomes in real-world settings. Routine use of tools like the BAM enabled multidimensional monitoring of progress despite challenges with retention and data completeness. Findings underscore the importance of flexible, patient-centered approaches to managing the chronic nature of SUD.

The online version contains supplementary material available at 10.1186/s13722-025-00625-3.

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