Written by National Director, Substance Use Policy and Programs, Alexandra Perry.
Whenever I meet with clients, the conversation around substance use and recovery almost always finds its way to return to work - often right at the very end.When it arrives, it brings a different kind of uncertainty: questions around roles, timing, and responsibility.
It’s important to say that this isn’t for lack of effort. There is a significant amount of thoughtful, well-intentioned work happening in this space. People care, systems are trying, and there is real investment in getting this right. And yet, even with all of that, it can still feel difficult to navigate. Who is responsible for what? When should decisions be made? And what do we mean when we say someone is “ready”?
This points to something deeper. Despite being one of the most critical points in the recovery journey, return to work is still often treated as a final step - something that happens after the work is done.
But in practice, this framing doesn’t hold. Return to work is not an endpoint, and it is not a simple handoff. It is an active part of the recovery process itself - one that directly shapes stability, relapse risk, and long-term outcomes.
This is why return-to-work planning needs to start as early as possible: ideally at the point of assessment, rather than at discharge or treatment completion. By the time we are asking whether someone is ready, we are often reacting instead of intentionally shaping the conditions for success.
This becomes even more important in the context of substance use, where recovery is ongoing and rarely follows a linear timeline. Someone may meet the criteria for return, but that does not mean their recovery is complete. In many cases, it is still actively stabilizing.
At the same time, individuals are often transitioning from highly structured treatment environments into workplaces where that level of support drops off significantly - and abruptly. Expectations change. Supports change. Yet individuals are required to function in a context that may not yet be aligned with where they are in their recovery.
I often think of this as a “cliff effect” - where support is reduced at the same time new demands are introduced. It is within this gap that risk begins to re-emerge.
In many ways, it is helpful to think about return to work not as discharge from care, but as part of a rehabilitation process.
If someone breaks their leg, we would not expect them to move directly from treatment back into full capacity without considering strength, alignment, and the conditions needed for recovery to hold. We wouldn’t expect them to just start running again. The same principle applies here.
Being cleared to return is not the same as being able to sustain function in a real-world environment. That plan needs to be built collaboratively - and it needs to account for where the person actually is, not where we hope they will be.
The evidence consistently shows that more stable return-to-work outcomes are associated with coordination across the system: between clinical providers, insurers, and the workplace, as well as early alignment around expectations, roles, and functional capacity.
Without that coordination, it is not uncommon to see returns that are technically approved but not truly supported. And it is within these situations - where the paperwork says yes but the conditions say otherwise - that relapse risk, functional decline, and re-disability can begin to surface.
In safety-sensitive environments, this becomes even more critical. Misalignment between capacity, environment, and role demands can have implications that extend well beyond the individual.
The opportunity here is not to do more, but to do things differently - more intentionally, more collaboratively, and more aligned with how recovery actually unfolds.
When thinking about return-to-work planning, I often come back to three core elements: alignment, environment, and function.
Alignment is about whether the role fits where someone is in their recovery. If someone is still stabilizing - in the first three months, for example - and we return them to a high-pressure role with tight deadlines, it can create strain quickly, even if the return looks reasonable on paper. We need to be mindful of the gap between what the role asks and what the person can genuinely sustain right now.
Environment is about what someone is walking back into. Is there space for flexibility? Can they speak up if they’re struggling? What does it look like when someone asks for help?
A workplace that allows for adjustment and open conversation will support recovery very differently than one that expects someone to come back at full capacity right away. The environment needs to support recovery for it to hold - the same way it does with any physical rehabilitation.
Function is about what someone can sustain, not just what they can do in a moment. Someone might present as ready in a structured or clinical setting, but the real question is whether that holds across a full workweek, in real conditions, over time, and without the same level of clinical support they had during treatment.
I hope this offers some useful perspective, and perhaps a few starting points for shifting the conversation.
Even something as simple as changing our language - from “return to work” to “work reintegration” - can begin to reflect the alignment and intentionality this process deserves. It signals that we are not just sending someone back. We are actively supporting them through one of the most demanding transitions in their recovery.
That distinction matters. And in my experience, it changes how people plan, how they communicate, and ultimately, how things go.
Alexandra Perry is National Director of Substance Use Policy and Programs at SOMA Medical. With a background in trauma-informed practice, organizational leadership, and clinical systems design, she works with insurers, employers, and healthcare providers navigating complex substance use and concurrent-disorder cases. Alexandra is currently completing her PhD in Industrial and Organizational Psychology.
Connect with Alexandra: Alex.Perry@somamedical.com