Peggy Shaughnessy

Title: From crisis to recovery to wellness: Building integrated pathways in addiction care

Abstract

Addiction and psychiatric distress increasingly overlap in frontline and community settings, yet many systems remain organized around episodic crisis response rather than long-term recovery and wellness. Across jurisdictions, individuals experiencing severe substance use, trauma-related dysregulation, suicidal ideation, housing instability, and justice involvement often cycle repeatedly through emergency departments, crisis teams, shelters, detox, short-term stabilization units, and brief outpatient interventions, with criminalization and incarceration frequently becoming part of the revolving door. While these services may prevent death in the immediate moment, they often lack the continuity required for recovery to become sustainable. This presentation argues that the most urgent risk is not only addiction itself but also the fragmentation of care pathways: people are harmed, relapse becomes predictable, and suicide/overdose risk escalates alongside justice cycling in the gaps between disconnected services.

Drawing on frontline program development at the RedPath Wellness Centre in Ontario, Canada, this presentation introduces an integrated chain-of-care model that moves individuals from crisis stabilization and harm reduction entry points into structured recovery, reintegration, and long-term wellness. The model is designed as a continuum rather than a set of stand-alone programs, with linked stages: (1) crisis and stabilization, (2) engagement and trust-building, (3) structured recovery programming grounded in routine, predictability, and restorative accountability, (4) restorative accountability and healing, (5) reintegration planning (housing stability, family repair, education/employment connection, community supports), and (6) wellness and belonging. A central principle of the model is that retention is treatment: continuity and sustained engagement are treated as primary clinical interventions rather than administrative measures. Relapse and destabilization are approached not as discharge triggers but as signals to adjust intensity and strengthen connection.

The presentation also addresses the addiction–psychiatry interface, highlighting an overlooked risk pathway in which medication may be prescribed appropriately but experienced amid mistrustful or fragmented care relationships. In such contexts, patterns of non-adherence, stockpiling, medication/substance combinations, and unregulated online substance sourcing may unintentionally elevate risk. Outcomes and evaluation markers used in this model will be presented, including engagement and retention (30/60/90 days), reduced reliance on crisis systems, reductions in justice cycling, housing stability indicators, and reconnection with family, education, and employment pathways.

Finally, the model’s international relevance will be discussed, as fragmentation is not jurisdiction-specific: in many countries, addiction care, psychiatric services, housing supports, and criminal justice responses remain siloed, leaving individuals to navigate complexity while in crisis. The key implication is that wellness becomes possible when continuity replaces fragmentation and integrated pathways replace revolving-door crisis care.

What will the audience take away from presentation?

A practical “integrated pathway” framework (crisis → recovery → wellness)

• How they can use it: Map their own service delivery into stages and identify gaps where relapse, overdose risk, and disengagement occur.


• Benefit: Helps program leaders and designers build continuity instead of fragmented referrals.

A model for trauma-informed structure and accountability

• How they can use it: Introduce rhythm-based programming, expectations, and engagement strategies without shame or coercion.


• Benefit: Helps clinicians and teams hold boundaries while maintaining therapeutic safety and trust.

Strategies to reduce revolving-door system use (ED, crisis, detox, short stays)

• How they can use it: Strengthen engagement, reduce dropout, and improve continuity between services.


• Benefit: Improves efficiency, reduces staff burnout, and lowers repeat crisis presentations.

A usable approach for working with complexity (addiction + mental health + housing + justice involvement)

• How they can use it: Integrate service planning across sectors rather than treating these as separate “referrals.”


• Benefit: Improves outcomes for high-acuity clients and reduces systemic fragmentation.

Transferable language and tools for implementation and teaching

• How they can use it: Apply the framework to research, teaching, service redesign, and program evaluation.


• Benefit: Supports faculty and teams in expanding research/teaching and designing better systems.