Transcript Principles of Recovery

National Perspective & Future Directions
H. Westley Clark, MD, JD, MPH, CAS, FASAM
Director
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
SAMHSA’s and CSAT’s Mission
and Future Directions
• Recovery is at the center of the Substance
Abuse and Mental Health Services
Administration’s (SAMHSA’s) mission.
• Fostering the development of recoveryoriented systems of care is a priority of the
Center of Substance Abuse Treatment (CSAT).
Past Month Alcohol Use
• Any Use:
52% (126 million)
• Binge Use:
23% (55 million)
• Heavy Use:
7% (16 million)
(Binge and Heavy Use estimates are similar to those in
2002, 2003, and 2004; Past month use increased
from 50% in 2004)
NSDUH 2005
Illicit Drug Use, by Age:
2002-2005
2002
2003
2004
2005
20.2 20.319.4 20.1
21
Percent Using in Past Month
18
15
11.6+11.2+
10.6 9.9
12
9
8.3 8.2 7.9 8.1
5.8 5.6 5.5 5.8
6
3
0
12 or Older
12 to 17
18 to 25
Age in Years
+
Difference between estimate and the 2005 estimate is statistically significant at the .05 level.
26 or Older
Non-medical Use of Prescription
Drugs, Ages 12+: 2002-2005
3
Percent Using in Past Month
2.6
2.7
2.5
2002
2003
2004
2005
2.6
3
2
1.9
2.0
1.8
1.9
2
0.8 0.8
0.7 0.7
1
0.5 0.5 0.5 0.4
1
0.2+
0.1 0.1 0.1
0
Any Psycho- Pain Relievers
therapeutics
+
Stimulants
Sedatives
Difference between estimate and the 2005 estimate is statistically significant at the .05 level.
Tranquilizers
Source Where Psychotherapeutics Were
Obtained for Most Recent Non-medical Use
among Past Year Users Aged 12 or Older: 2005
100
Other
Percent of Past Year Users
Bought on
Internet
80
Drug Dealer/
Stranger
60
1 or More
Doctors
40
Bought/Took
from Friend/
Relative
Free from
Friend/Relative
20
0
Pain Relievers
Tranquilizers
Methamphetamine
Stimulants
Co-Occurring Disorders
(5.2 million Adults)
Serious
Psychological
Distress
60%
Mood
Disorders
24.6 million Adults
Substance
Use
Disorder
General Population
Survey (NSDUH) 2005
Drug Use Disorder Treatment Seeking
Population (NESARC Study)
Denial, Stigma and Access to Care
Only an estimated 1.1 million adults received treatment for
illicit drug use disorders and 1.5 million adults received
treatment for alcohol use disorders in 2005
5.2 million adults
needed treatment for
illicit drug use disorders
but did not receive it
18%
16.4 million adults
needed treatment for
alcohol use disorders
but did not receive it
9%
8%
3%
Felt Need for TX,
but did not receive it.
Received TX
73% Felt No Need for TX
Illicit Drugs
89%
Alcohol
2005 NSDUH
Only an estimated 142,000 adolescents received treatment for
illicit drug use disorders and 119,000 received treatment for
alcohol use disorders in 2005
1.1 million adolescents
needed treatment for
illicit drug use disorders
but did not receive it
11%
1.3 million adolescents
needed treatment for
alcohol use disorders
but did not receive it
8%
3%
2%
Felt Need for TX, but
did not receive
Treatment
Received TX
86%
Illicit Drugs
Felt No Need for TX
90%
Alcohol
2005 NSDUH
Treatment and Recovery
Substance use disorders are too often viewed
by the funder and/or service provider
Severe
100
Person’s
Entry into
treatment
Discharge
Remission
0
Time
Tom Kirk, Ph.D
Current Service Response
Symptoms
100
Severe
Remission
0
Acute symptoms
Time
Discontinuous treatment
Crisis management
Tom Kirk, Ph.D
Tom Kirk, Ph.D
“addicts”
“a chronic, relapsing disease”
What message are we conveying?
Doesn’t anybody ever get better?
Recovery-oriented response
Symptoms
Severe
100
Continuous
treatment
response
Remission
0
TimeRehabilitation
Promote Self-Care,
Tom Kirk, Ph.D
Supporting People’s Path to Recovery
Symptoms
Severe
Improved client
outcomes
Remission
Time
Tom Kirk, Ph.D
Broadening the Continuum of Care
• Treatment is part of recovery, which is the
larger construct.
• Recovery support services are essential to
the recovery process.
Recovery Support Services
• Recovery support services are non-clinical services
that assist in removing barriers and providing
resources to those contemplating, initiating, and
maintaining recovery.
• Recovery support services should be made available
throughout the continuum of care:
–
–
–
–
Pre-treatment;
As an alternative to treatment;
During treatment; and
Post-treatment.
Examples of Recovery Support Services
• Assistance in finding housing, educational, employment
opportunities
• Assistance in building constructive family and personal
relationships
• Life skills training
• Health and wellness activities
• Assistance managing systems (e.g., health care,
criminal justice, child welfare)
• Alcohol- and drug-free social/recreational activities
• Culturally-specific and/or faith-based support
Social Support and Recovery Support Services
• Social support appears to be one of the potent
factors that can move people along the change
continuum (Hanna, 2002; Prochaska et al, 1995)
• Social support has been correlated with numerous
positive health outcomes, including reductions in
drug and alcohol use (Cobb, 1976; Salser, 1998).
• Four types of social support (emotional,
informational, instrumental, affiliational) have been
identified.
Emotional Support
Demonstrations of empathy, care, concern
• Mentoring, coaching, and support groups
Informational Support
Assistance with knowledge, information,
and skills
• Life skills training, job skills training,
citizenship restoration, educational
assistance, and health/wellness information
Instrumental Support
Concrete assistance in helping others get
things done
•Transportation to support groups, childcare, clothing, job application assistance,
etc.
Affiliational Support
Feeling connected to others, having a social
group and/or community, developing a prosocial identity in relation to a recovery
community
• Alcohol- and drug-free social and
recreational events; community and cultural
events
Peer-to-Peer Recovery Support Services
• Draws on the power of example
– e.g., instillation of hope; universality; social learning
• Draws on the desire to “give back”
– e.g., altruism; “survivor mission”, “wounded healer”
archetype
• Are based on notion that both people in a
relationship based on mutuality are helped and
empowered
– e.g., feminist & multicultural theory & practice; servant
leadership; 12-step tradition
Examples of Peer Recovery Support Services
• Peer coaching or mentoring
• Peer-led support groups
• Assistance in finding housing, educational,
employment opportunities
• Assistance in building constructive family and
personal relationships
• Life skills training
• Health and wellness activities
• Assistance in navigating systems (e.g., health care,
criminal justice, child welfare)
• Alcohol- and drug-free social/recreational activities
RCSP Portfolio
• 27 grants providing peer recovery support services
• 20 States
• Recovery community organizations and facilitating
organizations
• Diverse populations served
Population-Specific Services
• Women
• Self-defined groups by culture, ethnicity, sexual
orientation or religion
• Co-occurring disorders
• Ex-offenders
• Trauma survivors
• Families
• Age
Establishing a
Framework for a
Recovery-oriented
Approach
Recovery from alcohol and drug
problems is a process of change
through which an individual
achieves abstinence and improved
health, wellness, and quality of life.
Framework for Change
• National Summit principles and systems
elements are intended to provide general
direction for those operationalizing recoveryoriented systems of care.
• Principles and systems elements can inform
development of core measures, promising
approaches, and evidence-based practices.
Research Supporting Recovery Principles and
Recovery-oriented Systems of Care (ROSC)
• CSAT is developing a “White Paper” on research
supporting the National Summit guiding principles of
recovery and systems of care elements.
• Paper provides evidence that supports and validates
services and systems improvements based on
recovery-oriented approaches.
• White Paper will be a resource for policymakers,
providers, practitioners, recovery support staff, and
researchers to plan and implement ROSC.
• Copies of the Paper will be distributed at regional
meetings and via the Partners for Recovery website.
Preliminary Assessment of
Supporting Research
• At this stage in the development of the paper, over 130 articles
have been found to support the recovery principles (55
articles) and systems elements (84 articles).
• The white paper includes literature utilizing the following
types of qualitative and quantitative research designs:
– Case Studies, in-depth interviews, focus groups, quasiexperimental studies, and single group pre-post effectiveness
studies.
• Generally, 1/3 of the principles and systems elements are
supported by extensive research; 1/3 are supported by modest
research; and 1/3 are associated with minimal research.
Preliminary Assessment, cont’d
Extensive research supports the following
principles and elements:
Principles of Recovery
Systems of Care Elements
 Many pathways to recovery
 Person-centered
 Recovery involves a personal
recognition of the need for change
and transformation
 Individualized and comprehensive
services across the lifespan
 Recovery has cultural dimensions
 Recovery exists on a continuum of
improved health and wellness
 Recovery is supported by peers and
allies
 Recovery is a reality
 Ongoing monitoring and outreach
Preliminary Assessment, cont’d
A modest foundation of research supports the
following principles and elements:
Principles of Recovery
Systems of Care Elements
 Recovery is self-directed and
empowering






 Recovery involves addressing
discrimination and transcending
shame and stigma
 Recovery involves (re)joining and
(re)building a life in the
community
Family and ally involvement
Systems anchored in the community
Continuity of care
Strength-based
Culturally responsive
Responsiveness to personal belief
systems
 Integrated services
 Commitment to peer recovery support
services
Preliminary Assessment, cont’d
Minimal research supports the following principles
and elements:
Principles of Recovery
Systems of Care Elements
 Recovery is holistic
 Partnership-consultant
relationships
 Recovery emerges from hope
and gratitude
 Recovery involves a process of
healing and self-redefinition
 Inclusion of the voices and
experiences of recovering
individuals and their families
 System-wide education and
training
 Adequately and flexibly
financed
CSAT’s Commitment to Recovery
• CSAT is planning to infuse recovery principles
into our policies, programs, and products.
– We will also inform and support SAMHSA’s larger
efforts to promote recovery by offering substance
use disorder-related recovery ideas that can be
incorporated into the larger behavioral health
picture.
Access to Recovery
• Assures client choice of service providers;
• Implements a voucher system for clients
seeking substance abuse clinical treatment
and/or recovery support services;
• Conducts significant outreach to a wide range
of service providers that previously have not
received Federal funding, including faith-based
and community providers
• Monitors outcomes, tracks costs, and prevents
waste, fraud and abuse
ACCESS to RECOVERY
Connecticut’s Recovery-oriented Approach
Connecticut’s ATR Model
• High degree of collaboration with other targeted
State agencies
• Five regional networks - a total of 36 clinical and
130 recovery providers (including peer and faithbased) to ensure client choice
• One lead agency in each network assisting with
implementation, certification of providers, auditing,
etc.
Collaborative Agencies & Programs
•
•
•
•
•
Department of Correction
Judicial Branch
Department of Children and Families
Department of Social Services
Primary Healthcare Sites (Hospital ED & FQHC
Sites)
• DMHAS-funded Outreach &
• Engagement Urban Initiatives
Clinical Services
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•
•
•
•
•
Evaluation
Brief Treatment
Ambulatory Detoxification
Intensive Outpatient (IOP)
Methadone Maintenance
Recently implemented: an evidenced based
model of IOP for individuals using cocaine
and/or methamphetamines
Recovery Support Services
•
•
•
•
•
•
•
•
Short-term Housing
Case Management
Childcare
Transportation
Vocational/Educational Services
Basic Needs (food, clothing, personal care)
Faith-based Services
Peer-based Services
Two thirds of CT’s ATR service budget is invested in
Recovery Support Services, not clinical services.
More people working and in housing,
less inpatient costs
% Working
or in training
80
60
40
20
0
-20
-40
-60
-80
1
Inpatient costs
DMHAS established new
supportive housing units
for over 550 people with
psychiatric or substance
use disorders. Over 60%
of these people are now
working or in training, and
their inpatient costs have
decreased 70%.
Based on a Corporation
for Supportive Housing
study, these supportive
housing units are
projected to generate over
$140 million in direct and
indirect economic benefits
for the state.
Putting People to Work
Enhancing Employment and Self-Sufficiency through
Vocational Rehabilitation
The likelihood that a person served by DMHAS will become gainfully employed
is more than doubled when he/she receives vocational rehabilitation.
Receiving vocational services
Not receiving vocational services
0%
10%
20%
30%
40%
It pays!!
50%
Year To Date
August 3, 2004 – June 11, 2006
• 10,158 Unduplicated Individuals Served
– Year 1 Total Unduplicated Individuals: 106
– Year 2 Total Unduplicated Individuals: 10,032
• Received over 75,000 service level
authorizations (clinical and/or recovery support
services)
• $10,228,529 total paid claims
FY2007 ATR Funding
• Estimated Amount: $96 million
• The ATR program builds upon the successful initiative
established in FY 2004.
• A target of $25 million per year within ATR to address
methamphetamine
• Eligibility is limited to the immediate office of the
Chief Executive (e.g., Governor) in the States,
Territories, District of Columbia; or the head of an
American Indian/Alaska Native tribe or tribal
organization.
2007 ATR Grant
•
•
•
•
Posted March 23, 2007
Applications are DUE by June 7, 2007
Approximately 18 Awards to be funded
Applicants may request up to $7 million in
total costs (direct plus indirect).
– Grant award range: $1 million to $7 million
• Grants will be awarded for up to 3 years
Submission of ATR Applications
• Download required documents at
http://www.samhsa.gov/Grants/2007/TI_07_005.aspx
• No hand carried Applications
• Applications may be shipped or submitted
electronically
– DHL, FedEX, UPS or USPS
– www.Grants.gov
Conclusion
• Movement toward recovery-oriented systems of care
involves a significant systems-change.
• Recovery-oriented systems of care should:
– Encourage greater access to services;
– Intervene earlier with individuals with substance use
problems;
– Improve treatment outcomes; and
– Sustain long-term recovery for those with substance use
disorders.
SAMHSA/CSAT Information
• www.samhsa.gov
• SHIN 1-800-729-6686 for publication ordering
or information on funding opportunities
– 800-487-4889 – TDD line
• 1-800-662-HELP – SAMHSA’s National
Helpline (average # of tx calls per mo.- 24,000)