Transcript Patterns, supports, challenges and future directions

Exploring the recovery process:
Patterns, supports, challenges
and future directions
Alexandre B. Laudet
Presented at the Seminar Series of the Division of Epidemiology, Services
and Prevention Research (DESPR)
National Institute on Drug Abuse (NIDA)
April 20, 2005
Center for the Study of Addiction and Recovery
National Development and Research Institutes, Inc.
Correspondence: [email protected]
1
In collaboration with…
Co-Investigators: William L. White, Chestnut//Lighthouse
Gordon Storey, Self-Help Addiction Resource
Center (SHARC)
Statistician: Keith Morgen, NDRI
Operations: Virginia Stanick, and Marie Marthol, NDRI
Field: Jeffrey Becker, Wanda Bonilla, Nadina Correa, Una Cruz,
Doug Goldsmith, , Myrta Hernandez, Yolanda Jones, Vanessa
Rodriguez, Scott Smith, Luis Torres, NDRI
Design: Evette McCoy, NDRI
Background
This presentation draws on prospective and retrospective findings from
three NIDA-F studies using both quantitative and qualitative methods
to explore the recovery experience over time as well as factors that
promote and hinder the process.
The studies were/are conducted among inner-city participants in New
York City (details in handouts):
Pathways to long-term abstinence: Self-help processes,
R01DA14409
Twelve-step as aftercare: predictors and effectiveness,
R01DA015133Referral to self-help: Clients’ and clinicians’ views, R03 DA13432
Pathways Study Sample (N = 354):
Summary (see handouts)
Primarily members of inner-city ethnic, underserved minorities
Long & severe history of (primarily) crack and/or heroin use
Almost all are polysubstance users
Self-identified as ‘in recovery’ from one month to 10+ years
30% HepC+ and 22% HIV+
Almost all have used formal addiction treatment services and
12-step fellowships
Key Points
Need to make recovery a bona fide topic of research
Need to adopt long-term ‘career’ perspective
Need to identify multiplicity of recovery experiences, paths and
chronological patterns (stages) and their determinants:
Recovery challenges, resources
associated with the initiation,
maintenance of recovery
and unmet needs
consolidation and
Why study the
recovery process?
6
Why study the recovery process?
The prevalent view of addiction is that it is, for many, a lifelong
‘chronic’ disorder
However, stable recovery is a reality for millions of people
We know a great deal about active addiction patterns - there are
large databases about lifetime, past year and past month
substance use
We know about the process of recovery initiation through
treatment evaluation studies
“Looking at treatment to understand recovery is like looking at
birth to understand life” (Bill White)
Why study the recovery process? [2]
Recovery from a chronic disorder is process unfolding over time
We know little about temporal patterns of recovery over time or
about predictors of long-term recovery (recovery consolidation
and maintenance)
We know virtually nothing about the size or profile of the
recovering community in the US
Worse, we know little about how recovering persons achieve or
maintain their status over time
The drug field lags far behind the alcoholism field where several
long-term and prevalence estimates of recovery have been
conducted (e.g., Vaillant as well as Dawson 2005) - although more
is needed.
Why study the recovery process? [3]
Active addiction has multiple, high costs to the individual and to
society (ref. High HIV+ and HepC+ rates)
Understanding the recovery process and its determinants:
Inform program development and service delivery
Inform about needed supports and resources for the recovery
community
Learning from the experiences of the recovering community can
contribute to:
Give hope to active addicts and their family
Counterbalance the stigma of active addiction that leads to
discrimination for recovering persons –e.g., in the work place
“One of the great surprises of
longitudinal research is that you
discover that people do recover”
George Vaillant
10
What does
‘Recovery’ mean?
11
Public’s Perception Of “In Recovery”
From Faces & Voices of Recovery – April 2004/Hart Research and
Coldwater Corporation [National Random phone survey N = 801]
When you hear the word “recovery, as in “This person is in recovery
from an addiction,” what does “recovery” mean?
Person is free from
addiction/no longer
uses D&A
22%
Person is trying to stop
using D&A
62%
Person has been
damaged by D&A
Person has mental
illness
8%
3%
Pathways Participants
Recovery definition
Being drug-free (No
use of any D&A)
85.8
Not ANY drug, some
alcohol
No hard drugs, other
D&A OK
8
3.1
Other
1.7
Moderate/controlled
use of any drug and
alcohol
1.4
Recovery definition: so what?
While the recovery community largely defines ‘recovery’ as the
achievement of drug-free status, two-thirds of the the general
public defines it as an attempt to become drug-free (can it be
achieved?)…
This suggests that more work needs to be done to inform the
public that achieving drug-free recovery is a reality
Recovery patterns
Few long-term studies on recovery (<2 yrs)
Most conducted among alcohol-dependent persons
(e.g. Vaillant)
Findings suggest that although the course of
recovery varies across individuals, the likelihood of
sustained recovery increases over time (I.e., the risk
of relapse decreases over time)
Sustained drug-free recovery at F1 as a function of
baseline recovery stage (N = 287)
Pathways participants
86.4
84.2
57.5
43.6
Sustained recovery
F1
Under 6
mo.
Six to 18
mos.
18 to 36
mos
Three+
years
43.6
57.5
86.4
84.2
Recovery patterns
Evidence that the risk of relapse remains, even after
several years of abstinence….
We examined retrospective recovery patterns among
Pathways participants
Pathways to Long-Term Abstinence
Relapse History (n=354)
Since starting regular drug use, did you ever have one or more period (s)
of complete abstinence of one month or longer followed by return
to active addiction?
Yes
71%
Relapse History
Number of clean periods followed by return to active addictionb
Over 50% reported 4 or more abstinent periods
followed by return to active addiction
One
17%
20 & over
10%
Ten to 19
17%
Two
22%
Six to nine
7%
Three
11%
Four to five
16%
Range 1 to 90 Mean = 7.56; Std dev= 10.6
b
Among those who report one or more such periods: N=248- 5 “don’t know”
Length of longest ‘clean’ period
before return to active addictionb
50% had one or more clean periods of one year or longer28% had one of 3 years or longer before slip/relapse
One month
8.3
Two to five months
17.1
Six to eleven months
18.3
One to under two years
15.5
Two to under three years
12.3
Three to under five years
11.5
Five years and over
17.0
0
5
10
Ranges= 1 to 120 Mean = 23.6 Std dev= 27.9
B
Among those who report one or more such periods: N=253
15
20
Length of relapse after longest
clean period b
63% of respondents say relapse lasted over one year
6% 4%
25%
16%
11%
18%
5 yrs & over
2 to under 5 yrs
One to under 2 yrs
Six to 11 mons.
Two to 5 mos.
One month
Under one month
20%
Range = > one month to 16 yrs Mean =36.3; Std dev= 49.3
b
Among those who report one or more such periods: N=253
Relapse patterns: Relevance
One quarter of pathways participants are HIV+, 30% HepC+
Increased likelihood of risky behaviors (e.g., unprotected sex,
multiple partners) during active addiction
NEED TO ELUCIDATE BARRIERS TO SUSTAINED RECOVERY
AND SUCCESFUL STRATEGIES TO SUSTAIN RECOVERY
Relapse after Recoveryb
What got you back to using? Top answers (<10%)
38.9
...
, mo n
s
g
u
r
., d
s (e.g
r
e
g
g
tri
sed to
o
p
x
E
32.2
n
it uatio
s
/
t
n
e
v
sful e
Stres
12.3
to use
d
e
t
n
a
ving/w
a
r
c
/
e
Urg
n
uld ha
o
c
t
l
Fe
B
ted
addic
s
a
w
tI
f or go
/
t
i
e
l
d
10.3
0
5
10
15
20
25
30
Among those who report one or more such periods: N=253
35
40
45
Relapse after longest clean periodb
Lessons learnt Top answers (<10%)
Must want recovery/work on it
continously/make it a priority
21.8
Being clean is a positive/drugs
negative/bad place to be
18.7
Learn about/stay away from triggers
18.3
Cannot recover without support
Need to address underlying
issues/express feelings
I am an addict/can't use socially
B
15.1
11.5
10.3
Among those who report one or more such periods: N=253
Strategies to deal with recovery challenges
c
Pathways participants
Seeking support and staying focused
Distraction
6%
Mediate/pray
8%
Seek
help/support,
Talk about pb
44%
Stay focused
42%
C
Among those who report a challenge
Recovery patterns summary
The risk of relapse remains well into the recovery process
Stress, exposure to triggers, temptations/urges, and belief that
one can control drug use are recovery challenges and key
factors in return to active addiction
Making recovery a priority, staying focused on recovery and
seeking support are identified as helpful strategies
Recovery Capital
27
Recovery Capital
Recovery capital refers to the amount and quality of Internal and
external resources that one can bring to bear to initiate and
sustain recovery from addiction
A number of factors have been identified as predictors of recovery
in short-term studies and constitute recovery capital
They include:
Cognitive recovery readiness
Participation in 12-step fellowships
Faith/spirituality/life meaning
Recovery Capital
Cognitive recovery readiness
29
Cognitive recovery readiness
Cognitive domains associated with enhanced recovery outcomes in
process research include:
Generic processes common to several addiction treatment
orientations such as drug abstinence self-efficacy, motivation and
coping; and
Processes that are unique to the disease (Minnesota) model:
Embracing the disease view of addiction as a lifelong disorder
Admitting powerlessness over drugs and alcohol,
Accepting the need for/believing in a Higher power,
Commitment to 12-step fellowships (intention to attend 12step groups), and
identifying with others in recovery.
Increasing/higher levels of these cognitive processes found to be
associated with better subsequent substance use outcomes.
Mean score (scale range = 1 to 5)
Cognitive Recovery Readiness
across Stages of Change
4.2
4.0
3.8
Asbtinence
3.6
self-efficacy
Recovery readiness*
3.4
Precontemplation
Contemplation
STAGE OF CHANGE
Disease model beliefs + motivation and coping
(i.e., all but self-efficacy)
Action
Cognitive Recovery Readiness
as a function of help seeking career
Prior treatment here – same trend with prior 12-step attendance
5.0
Mean score
4.5
4.0
3.5
Abstinence
3.0
self-efficacy
Recovery readiness*
2.5
None
One
Two
3-4
5-9
10+
NUMBER PRIOR TREATMENT EPISODES
* Disease model beliefs + motivation and coping
(i.e., all but self-efficacy)
So, Cognitive recovery readiness…
Increases over stages of change
Increases as a function of cumulative recovery help seeking
(treatment and 12-step)
Recovery Capital
12-step fellowships
34
Background
• In the United States, 12-step groups (e.g., Alcoholics and
Narcotics Anonymous) are both the most prevalent types of
self-help groups and the most common source of help sought
by people with substance abuse problems.
• Participation in 12-step groups during and after formal
treatment associated with reduced rates of substance use
• Concurrent use of 12-step and formal treatment has been
shown to have additive effects
12-step affiliation and sustained recovery
Effectiveness: Twelve step affiliation (attendance and
involvement) significantly associated with
subsequent positive (sustained) recovery outcome…
Effectiveness: Sustained abstinent recovery at F1 as
a function of baseline level of 12-step attendance
and affiliation
.8
.7
.6
.5
Consider self member
Stepwork
.4
Attended 12-step
past yr
.3
No
Sustained recovery
Sustained abstinent recovery at F1
12-step attendance:
Patterns and attrition
38
12-step Attendance patterns
Aftercare participants (N = 314)
Disengaged
23%
Never
attended
19%
Attended
past year
58%
12-step attrition: Ever dropped out?
Since you fist started attending, have you ever stopped
attended for one month or longer? (yes)
100%
85%
91%
75%
50%
25%
0%
Narcotics
Anonymous
Alcholics
Anonymous
Perceived helpfulness
and benefits of 12-step
groups
41
Attitudes about 12-step among Drug
Treatment Clients e
Helpfulness of
12-step
8.02
Importance of
12-step in
treatment
7.86
Importance of
12-step in
recovery
process
8.70
7.4
e
7.6
Scale range from 0 to 10
7.8
8
8.2
8.4
8.6
8.8
Reasons for 12-step attendance
0
20
40
f ,g
60
59
om
Pr
Su
t/ a
r
o
pp
To
k
ma
ep
c
c
ri
ef
tep
e
o
c
e
sr
e
t
o
c
n
a
t
s
nd
el
f
/
e
, to
r k,
o
w
c
41
ry
ve
33
58
..
lo.
4
..
k
c
he
itu
r
i
sp
ty
i
l
a
4
3
8
Narcotic Anonymous
Alc. Anonymous
S
F
among ‘ever’ attenders; g Add to < 100% because up to 3 answers were coded
Quandary:
12-step attrition and non-affiliation
12-step fellowships generally viewed as helpful and beneficial
to recovery
Yet, some never attend and many disaffiliate over time
One of the most important tasks for clinicians is to foster stable
engagement in 12-step groups to facilitate clients’ transition
into the post-treatment phase of recovery.
What are some of the reasons why substance users do not
attend/leave 12-step?
Obstacles to 12-step
affiliation and reasons
for non-attendance
45
Why did you stop attending 12-step?
g
(longest interrupted period)
33
26
25
15
t
No
G
a
y /w
d
rea
ng
nti
to
os
s in
u
p
t
Did
li
n't
g
k
ire
/t
e it
f
do
do
n
Ca
it
nm
o
t
i
wn
o
y
Add to < 100% because up to 3 answers were coded
a ti
c
o
e /l
m
i
T
13
5
ul
on
t
No
c
Un
lpf
e
h
ble
a
t
for
m
o
s
g
rin
a
h
Observation…
Reasons cited for not attending 12-step groups mirror the
lessons learnt from relapse and helpful strategies to recover:
Don’t want to stop vs. make recovery a priority
Can do it on my own vs. seek support
THIS SUGGESTS THAT MOTIVATION AND ACCEPTING NEED
FOR/SEEKING SUPPORT FOR RECOVERY ARE CRITICAL
Recovery Capital
Spirituality, Faith and Life meaning
48
Baseline Spirituality, Religiosity, Life meaning
and Recovery @ F1
6.0
5.5
Mean
5.0
4.5
4.0
3.5
Spiritual well-being
3.0
Life meaning
2.5
Religiosity
No
Yes
Sustained abstinent recovery at F1
Pathways Pilot
Spirituality and religion as Recovery support (N=52)
Describe any religious/spiritual experience/ support that you have had as a significant part
h
of your recovery
38
Organized religion, church
12-step recovery program and
fellowship
34
Spiritual God/Higher
Power/spirituality
33
Spiritual
awakening/experience
16
14
Support from peers
12
God (non-specific)
10
None
Surrender/admitted
powerlessness
8
Community invoolvment
,volunteer work/service
2
0
h
5
10
15
20
Adds up to < 100% because up to 3 answers were coded
25
30
35
40
Pathways to Long-Term Abstinence
Sources of strength and support in recoverya
53
aith
f
/
y
t
i
itual
r
i
p
S
ily
Fa m
eer s
p
g
in
over
c
e
R
use
o
p
S
ngth
e
r
t
er s
n
n
i
/
f
Sel
nds
Frie
s
ician
n
i
l
C
53
43
18
17
11
7
0
10
20
30
40
50
60
70
80
90
100
So, spirituality/religion…
Cited as critical source of recovery support
Associated with sustained recovery over time
Why do substance users
seek recovery?
53
Pathways to Long-Term Abstinence
Factors Associated with Decision to Quit
“To what extent was [item] a factor in your decision to stop using drugs this time?
“Not at all, a little, moderately, very much, extremely.”
Didn't like where life was
going/feared consequences
94
Desire for a better life
93
Tired of the drug life
92
Didn't like what I was becoming
90
Weighing pros & cons of
continued use
86
Negative effects of drug use on
others
83
50
75
100
Recovery: The hard road to a better life?
Many recovering substance users report that they stopped using
drugs because they wanted a better life.
They see initiating recovery as the path to a better life
It is a challenging and stressful path for most
We conducted a study that addressed two questions
First: Does quality of life improve as recovery
progresses?
Stress and Life Satisfaction as a
Function of Length of Recovery (N = 354)
Mean (scale range = 0 to 10)
8.5
8.0
7.5
7.0
6.5
6.0
Overall life
5.5
satisfaction
5.0
Stress rating pst yr
>6 months
18 to 36 mos
Six to 18 mos
RECOVERY STAGE
3+ years
Does recovery capital buffer stress
among persons in recovery?
Stress frequently cited as a relapse trigger
Second question: Do factors previously identified separately as
buffering stress or promoting stable recovery contribute to
enhancing QOL among recovering persons
We tested a model that hypothesized that RECOVERY CAPITAL
-social support, spirituality, life meaning, religious practices,
and affiliation with 12-step fellowships - buffers stress and
enhance quality of life satisfaction.
We found…
Recovery capital: Buffering Stress
and Enhancing Quality of Life in recovery j (N = 354)
RECOVERY CAPITAL ACCOUNTS FOR 60.6% OF VARIANCE IN QOL
Spirituality
17%
General Social suprt 9.6%
Stress
Length of recovery
9.1%
Religiousness
8.5%
Recovery support
7.3%
Life meaning
5.6%
12-step involvement 3.5%
12-step attendance
j
0
All betas p<.001 except 12-step attendance
Quality
of life
Recovery capital as predictor of
sustained abstinent recovery at F1
We conducted a preliminary examination of predictors of sustained abstinent
recovery at F1 to determine whether the same or different factors predict
sustained recovery at different stages of the process
Multiple regression analyses were conducted on the whole sample and on each
of the four baseline recovery stage groups
Hypothesized baseline predictors of sustained abstinent recovery @ F1:
Lifetime severity
Length of recovery @ base
27%
Commitment to abstinence
Self efficacy
39%
12-step involvement
Under 6 mos.
Embracement disease model
6 to 18 mos.
12-step attendance past yr
18 to 36 mo.
Three+ yrs
Recovery support
Spiritual well-being
21%
Religiosity
Life meaning
21%
Life satisfaction
Stress past month
Predictors of sustained recovery @ F1:
Total sample and baseline recovery stages N = 287
Predictors of sustained recovery appear to differ across recovery stages…
Total
% variance explained
15%
Lifetime severity
Length of recovery @ base
Commitment to abstinence
Embracement disease model
12-step attendance pst yr
Recovery support
Religiosity
Life meaning
x
x
ns
ns
ns
ns
ns
x
> 6 months 6 to 18 mos. 18 to 36 mos.
3 yrs +
23%
32%
12%
15%
x
x
ns
x
x
x
ns
ns
x
x
ns
ns
ns
ns
x
ns
ns
ns
ns
ns
x
ns
ns
x
ns
ns
ns
x
ns
ns
ns
x
Predictors of sustained recovery
Preliminary findings suggest that different sets of factors are
associated with sustained recovery at different recovery stages
Much of the variance in sustained recovery remains
unexplained and much more work is needed
Recovery revisited…
Beyond drug use & abstinence
62
“If you want to treat an illness that has no
easy cure, first of all, treat them with hope”
George Vaillant
63
Recovery definition revisited
Pathways participantsg
How would you define "recovery from drug and alcohol use"?
Please be as specific as you can. [RECORD VERBATIM]
RECOVERY GOES BEYOND SUBSTANCE USE
Better life/new life
72
Total abstinence
31
Lifelong process/working on self
24
Dealing with issues/seeking help
24
0
G
10
Add to < 100% because up to 3 answers were coded
20
30
40
50
60
70
80
Positive aspects of recovery
Pathways participantsg
r hea
Clea
of m
e
c
a
d/pe
49
tude
i
t
t
a
s&
i ence
r
e
p
e ex
v
i
t
i
s
po
goal s
+
g
/
r
n
i
e
Bet t
chi ev
a
&
ng
Havi
t ions
i
d
n
i fe co
l
r
e
t
Bet
ealth
h
r
e
t
Bet
i ons
t
a
l
e
cial r
o
s
r
Bet te
0
G
62
ind
21
17
10
9
10
20
Add to < 100% because up to 3 answers were coded
30
40
50
60
70
Integration of Findings
Achieving sustained recovery is a reality
Recovery appears to be the road to a better life
There are many challenges along the way: stress, urges to use, denial of
problem
There are potentially costly slips and relapses along the way
Keeping focused on recovery, learning to deal with stress, and seeking
support are key to maintaining recovery
This translates into the need for ‘recovery capital’: motivation, accepting
the problem and working on it (12-step ideology), seeking support from
peers (e.g., 12-step fellowships), faith, and a sense of meaning/purpose
Although recovery in the US is largely defined as “abstinence from all
drugs and alcohol”, the recovery experience goes beyond substance use
and represents a new life, a better life, new hopes and opportunities
Preliminary evidence indicates that different factors are critical to recovery
at different ‘stages’
Looking forward…
MEASUREMENT and RESEARCH ISSUES
67
Defining Recovery
Is recovery a time-limited event (a state) or a time-extending process? If
addiction is a chronic disorder, recovery may be a process unfolding through
(below) non mutually exclusive stages – from partial to full remission?
When is recovery achieved? Under what circumstances is it lost or brought to
completion?
DSM-IV-R – Possible recovery stages from partial to full remission
Sub- clinical: Past year user who does not meet the DSM-IVR criteria for
dependence but reported 1+ symptoms of either abuse or dependence?
Problematic use: Past-year risk user (see above) with no symptoms of
either abuse or dependence in the past 12 months?
Non- problematic use: Past year substance user with no symptoms of
either abuse or dependence and not classified as a past-year risk user?
No use: No past year substance use (complete abstinence)?
Investigating Recovery: How?
The empirical investigation of the recovery experience over time
requires methods that differ from those typically used when
conducting treatment evaluation studies.
For example….
RECRUITMENT
Persons in recovery are “from all walks of life.”
Recruiting a representative sample of recovering persons
requires strategies that cast a wide net across ethnic groups,
social strata, substance use histories and recovery paths.
Media advertisement has been the most frequently used and the
most effective strategy for recruiting diversified samples of
recovering persons (see handout)
We’ve only just begun…
Where do we go from here?
70
Toward a Recovery-Oriented Research Agenda
1. Use a telescope, not a microscope (George Vaillant) – I..e.,
Adopt a long-term, natural history ‘career’ perspective to elucidate:
Multiplicity of recovery experiences, paths and chronological patterns
(stages)
Determinants (promoting/hindering factors) of these paths and patterns
over time
Among subgroups as the recovery experience/paths/needs may differ:
e.g, gender, ethnicity and age groups, HIV+, dual-diagnosis, high/low
problem severity, high/low recovery capital
Across cultures where different socio-political views of addiction and
different models/options of service delivery prevail (‘universal’ and
culture-specific factors)
2. Achieve consensus on how to define and measure recovery
In terms of substance use; and in
Global health, e.g., physical, emotional, relational, and occupational
health and responsible citizenship
Toward a Recovery-Oriented Research Agenda
3. Identify challenges, professional & indigenous resources and unmet
needs associated with the initiation, consolidation and maintenance of
recovery
e.g., What sources of support are being used in addition to those
previously identified (treatment, 12-step) such as faith, community
involvement
Role of family in the individual recovery process as well as stages
of family recovery (family as whole and family subsystems)
Role of stigma as obstacle to recovery initiation and maintenance
4. Assess the long-term consequences of various recovery paths (e.g.,
psychosocial and cognitive/brain functioning in medically-assisted vs.
drug-free recovery)
5. Integrate empirical findings about the recovery process into existing
knowledge about addiction to promote:
A paradigm shift in service delivery and assessment from the
current ‘acute’ model to sustained recovery management
Societal awareness about the reality and hope of recovery and the
multiple pathways to long-term recovery
Questions?
Thank you.