Transcript What is Treatment and What is it Supposed to Do?

“Recovery” from Drugs and
Alcohol Use: Current Models of Recovery
Support Services
Richard Rawson, Ph.D.
Integrated Substance Abuse Programs
University of California, Los Angeles
Talk Objectives
1. Define “recovery”
2. Define a “recovery oriented system of care”
3. Identify different models of recovery support services
4. Identify recovery support service models that are
evidence based and/or their limitations.
Many Pathways to Recovery
• There is no single treatment strategy that is
known to produce a “cure” for substance
use disorders.
• There are many pathways to Recovery
What is Recovery?
Recovery is a voluntarily maintained lifestyle
comprised of sobriety, personal health and
citizenship.
Betty Ford Consensus Panel, 2007
RECOVERY
Recovery from alcohol and drug problems is a
process of change through which an
individual achieves improved health,
wellness, and quality of life.
A.A./N.A. Survival in Historical
Context
Long series of pre-AA recovery mutual aid societies
dating from 1730s
• Abstinence-based cultural revitalization
movements
• Washingtonians, Fraternal Temperance Societies,
Ribbon Reform Clubs, Institutional Support
Groups.
• Few organizationally survived their founding
generation
The Twelve Steps
and
Twelve Traditions
Alcoholics Anonymous
12 Steps
• “Alcoholics Anonymous is a fellowship of men and
women who share their experience, strength and hope
with each other that they may solve their common
problem and help others to recover from alcoholism.
• The only requirement for membership is a desire to stop
drinking. There are no dues or fees for A.A.
membership; we are self-supporting through our own
contributions. Our primary purpose is to stay sober and
help other alcoholics to achieve sobriety.”
Alcoholics Anonymous
12 Steps
Here are the steps we took, which are suggested as a
program of recovery:
1. We admitted we were powerless over alcohol, that our lives had
become unmanageable.
2. Came to believe that a Power greater than ourselves could restore
us to sanity.
3. Made a decision to turn our will and our lives over to the care of
God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
Alcoholics Anonymous
12 Steps
5.
6.
7.
8.
9.
Admitted to God, to ourselves, and to another human being the
exact nature of our wrongs.
Were entirely ready to have God remove all these defects of
character.
Humbly asked Him to remove our shortcomings.
Made a list of all persons we had harmed, and became willing to
make amends to them all.
Made direct amends to such people wherever possible, except
when to do so would injure them or others.
Alcoholics Anonymous
12 Steps
10. Continued to take personal inventory and when we were wrong
promptly admitted it.
11. Sought through prayer and meditation to improve our conscious
contact with God as we understood Him, praying only for
knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we
tried to carry this message to alcoholics, and to practice these
principles in all our affairs.
Spiritual Frameworks of Recovery
Twelve-Step Groups, e.g., -AA (1935) and NA
(1947, 1953)
Drug Choice Adaptations: marijuana (1968, 1989),
prescription drugs, (1975, 1998), cocaine (1982)
nicotine (1985), benzodiazepine (1989),
methamphetamine (1995), heroin (2004), persons
in recovery on methadone (1991).
Non-Twelve Step, Spiritual Alternatives
AA Shared with Earlier Groups
(Not Derivative)
• Problem admission
• Public or semi-public commitment to
sobriety
• Sober fellowship
• Experience-sharing meetings
• Storytelling (3-part style)
• Peer mentoring
AA Innovations
• Self-surrender versus self-assertion
• Focus on long-term recovery maintenance
versus recovery initiation
• Middle path between religious and secular
pathways of recovery
• Codification of program in writing prior to
explosive growth
AA Innovations
• Maintained its closed meeting framework
--import of identification in recovery process
• Unique organizational structure (that all external
advisors predicted could not work)
• Creative management of the 5 Ps: personality—
particularly charismatic leadership,
power/privilege, possessions (money and
property), press and passion
• Twelve Traditions were/are key to AA’s survival
Further Specialization
Family
Al-Anon (1951), Alateen (1957), Families
Anonymous (1971), Recovering Couples
Anonymous (1988) & Teen-Anon (1999)
Occupational
International Doctors in Alcoholics Anonymous
(1949), Lawyers (1975), Anesthetists (1984),
Nurses (1988), Veterinarians (1990), etc.
Further Specialization
Co-Occurring Problem
Dual Disorders Anonymous (1982),
Dual Recovery Anonymous (1989),
Double Trouble in Recovery (1993)
How A.A./N.A. Survived: The
Twelve Traditions
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•
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Role of unity in recovery
Group conscience / servant leadership
Singular membership requirement
Group autonomy
Singularity of purpose
Organizational autonomy
How A.A./N.A. Survived: 12
Traditions
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•
•
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Financial self-sufficiency
Nonprofessional status of mutual support
Organizational minimalism
Organizational silence (on outside issues)
Public relations by attraction
Anonymity
Secular Recovery Support Groups
• Women for Sobriety (1975)
• Secular Organization for Sobriety / Save Our
Selves (1985)
• Rational Recovery (1986)
• Men for Sobriety (1988)
• SmartRecovery® (1994)
• Moderation Management (1994)
• LifeRing Secular Recovery (1999)
Importance of Mutual
Identification
The “secret” of Alcoholics Anonymous, the
thing that makes A.A. work, is
identification. As Marty Mann is reputed to
have said to her fellow sanitarium inmate
on returning to Blythewood from her visit to
the Wilson home in Brooklyn Heights for
her first A.A. meeting: “Grennie, we aren’t
alone any more.” (Kurtz, 2002)
Summation
The birth and early survival of A.A. & N.A. were
rooted within unique historical contexts.
AA & NA (and all other addiction recovery mutual
aid societies) are facing fundamentally new
contexts in which they will have to reaffirm or
redefine their future identities.
Summation
These new contexts include the expanding varieties
of recovery experience, increased institutionbuilding within the American culture of recovery,
growing professionalization & commercialization
of peer recovery support, and an emerging science
of addiction recovery.
These contexts present both threats & opportunities
to the future of AA, NA and other recovery mutual
aid groups.
Recovery Home Movement
• Halfway Houses (1950s) to Social Model
Rehabilitation Programs (1970s)
• Oxford House (1975) (1,200 homes, 48 states,
24,000 residents per year)
• Federal Anti-Drug Abuse Act of 1988 (Loan
Fund)
• Broader Recovery Home Movement
• Philadelphia Survey (21 funded; 250 unfunded)
What is a Recovery-oriented System of Care?
Networks of formal and informal services
developed and mobilized to sustain longterm recovery for individuals and families
impacted by severe substance misuse.
Benefits of recovery: Open-endeda
What, if anything, is/would be good about being in recovery?
RECOVERY = A BETTER LIFE
•a Add to > 100% because up to 3 answers were coded
•Stress and Quality of Life Satisfaction as a
Function of abstinence duration (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
3+ years
RECOVERY STAGE
•Laudet, Morgen & White, Alc. Tx Q. 2006
Recovery definition: Open-endeda
How would you define "recovery from drug and alcohol use"?
RECOVERY GOES BEYOND SUBSTANCE USE
44%
Better life/new life
41%
Total abstinence
21%
Lifelong process
17%
Dealing w/issues
0
10
20
30
• Laudet, JSAT, 2007
40
50
Priorities @ outpatient admission
What are the priorities in your life right now? (N = 314)
•Abstinence is top
goal but not only
goal!!!
Life priorities in recovery by abstinence duration
“What are the priorities your life right now?”
•Laudet & White, JSAT 2009
(N = 354)
Defining Recovery Support Services
• Recovery support services include social support,
linkage to and coordination among allied service
providers, and a full range of human services that
facilitate recovery and wellness contributing to an
improved quality of life.
• They may be delivered by peers, professionals, faithbased and community-based groups, and others.
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Models of Recovery Support Services
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Self/mutual help programs
Medications
Traditional counseling visits
Recovery Centers
Recovery “Check-ups”
– Specialty & Primary care-based
• Home visits
• Telephone-based protocols
– Monitoring, feedback and counseling
• Assertive Continuing Care
Data on 12-Step Programs
Summary of Findings (Humphreys, 2004)
• Longitudinal studies associate AA and NA participation
with increased abstinence, improved social functioning,
and greater self-efficacy.
• Participation seems more helpful when members engage in
other group activities in addition to attending meetings.
• 12-step self-help groups significantly reduce health care
utilization and costs, removing a significant burden from
the health care system.
Donovan DM (June 2-3, 2008). Evidence for 12-Step Facilitation. Presentation at the NIDA
Blending Conference, Blending Addiction Science & Treatment: Accessible at:
http://ctndisseminationlibrary.org/PDF/274a.pdf.
Data on 12-Step Programs
Conclusions (Humphreys, 2004)
• Self-help groups are best viewed as a form of
continuing care rather than as a substitute for acute
treatment services
Donovan DM (June 2-3, 2008). Evidence for 12-Step Facilitation. Presentation at the NIDA
Blending Conference, Blending Addiction Science & Treatment: Accessible at:
http://ctndisseminationlibrary.org/PDF/274a.pdf.
•12-step groups have established themselves
in the once-impenetrable Middle East
•Note: NA is for all drugs not just narcotics
Selected data on clinical and costeffectiveness
Clinical trial of Oxford House
• Oxford House is a 12-step influenced, peermanaged residential setting
• 150 Patients randomized after inpatient
treatment to Oxford House or TAU
• 77% African American; 62% Female
• Follow-ups every 6 months for 2 years,
90% of subjects re-contacted
At 24-months, Oxford House (OH)
produced 1.5 to 2 times better
outcomes
•Jason et al. (2006). Communal housing settings enhance substance abuse recovery. American J Public Health, 96, 1727-1729.
Veterans Affairs RCT on AA/NA
referral for outpatients
• 345 VA outpatients randomized to standard
or intensive 12-step group referral
• 81.4% FU at 6 months
• Higher rates of 12-step involvement in
intensive condition
• Over 60% greater improvement in ASI
alcohol and drug composite scores in
intensive referral condition
•Source: Timko, C. (2006). Intensive referral to 12-step self-help groups and 6-month substance use disorder
outcomes. Addiction, 101, 678-688.
Alcohol-related outcomes of 201 individuals
initially selecting AA (n = 135) or outpatient
treatment (n = 66)
Data on 12-Step Programs
Summary of Findings (Donovan, 2008)
• Longitudinal studies usually find that 12-Step involvement
after treatment is associated with higher rates of abstinence
regardless of the kind of treatment received;
• Consistent and early attendance/involvement leads to
better substance use outcomes;
• Small amounts of participation may be helpful in
increasing abstinence, whereas higher doses may be
needed to reduce relapse intensity.
Donovan DM (June 2-3, 2008). Evidence for 12-Step Facilitation. Presentation at the NIDA
Blending Conference, Blending Addiction Science & Treatment: Accessible at:
http://ctndisseminationlibrary.org/PDF/274a.pdf.
Data on 12-Step Programs
Summary of Findings (Donovan, 2008)
• Attendance is not involvement; when AA attendance
and AA involvement (e.g. reading 12-step literature,
getting a sponsor, “working” the steps, or helping set
up meetings) are both measured, involvement is a
stronger predictor of outcome; and
• Reductions in substance use associated with 12-Step
involvement are not attributable to…influences such
as motivation, psychopathology, or severity.
Donovan DM (June 2-3, 2008). Evidence for 12-Step Facilitation. Presentation at the NIDA
Blending Conference, Blending Addiction Science & Treatment: Accessible at:
http://ctndisseminationlibrary.org/PDF/274a.pdf.
A Continuing Care Model
•Detox
•Duration
•Determined by
•Performance
•Criteria
•Rehab
•Continuing Care
•Recovering Patient
Recovery Management Checkups
• An early re-intervention experiment evaluated the
impact of a Recovery Management Checkup (RMC)
protocol.
• Included quarterly recovery management checkups
(assessments, motivational interviewing, and linkage
to treatment re-entry).
An experimental evaluation of recovery management checkups (RMC) for people with chronic substance use
disorders. Dennis ,M., Scott, C. and Funk, R. Evaluation and Program Planning 26, 2003, 339-352
Recovery Management Checkups
Intervention
• If patient reports any of the following……
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–
–
–
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Use of alcohol or drugs on > 2 weeks
Being drunk or high all day on any days
Alcohol/drug use led to not meeting responsibilities
Alcohol/drug use caused other problems
Withdrawal symptoms
…Patient transferred to linkage manager
An experimental evaluation of recovery management checkups (RMC) for people with chronic substance use
disorders. Dennis ,M., Scott, C. and Funk, R. Evaluation and Program Planning 26, 2003, 339-352
Recovery Management Checkups
Intervention
• Linkage Manager provided the following:
–
–
–
–
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Personalized feedback
Explored possibility of returning to treatment
Addressed barriers to returning to treatment
Scheduled an intake assessment
Reminder cards, transportation, and escort to intake
appointment
An experimental evaluation of recovery management checkups (RMC) for people with chronic substance use
disorders. Dennis ,M., Scott, C. and Funk, R. Evaluation and Program Planning 26, 2003, 339-352
Recovery Management Checkups
Results
• Participants assigned to RMC were significantly more
likely to:
– Return to Treatment
– Return to treatment sooner;
– Spend more subsequent days in treatment; and
– They were significantly less likely to be in need of
additional treatment at 24 months
An experimental evaluation of recovery management checkups (RMC) for people with chronic substance use
disorders. Dennis ,M., Scott, C. and Funk, R. Evaluation and Program Planning 26, 2003, 339-352
Recovery Management Checkups
Conclusions
• These findings support the need and effectiveness of
post-discharge monitoring and checkups.
An experimental evaluation of recovery management checkups (RMC) for people with chronic substance use
disorders. Dennis ,M., Scott, C. and Funk, R. Evaluation and Program Planning 26, 2003, 339-352
Assertive Continuing Care
Study Overview (Godley et al, 2006)
• Compared assertive continuing care (ACC) to usual
continuing care (UCC) on linkage, retention and a measure
of continuing care adherence.
• A total of 183 adolescents, ages 12–17 years, with one or
more DSM-IV substance use dependence disorder.
• ACC approach included assertive outreach by a case
manager that included home visits and implementation of
components of the community reinforcement approach.
The effect of assertive continuing care on continuing care linkage, adherence and abstinence following residential
treatment for adolescents with substance use disorders. Godley, M., et al. Addiction, 2006, 102, 81-93.
Assertive Continuing Care
Study Overview
• Prior to discharge from residential treatment,
participants were assigned randomly to receive either
UCC, available at outpatient clinics in the 11-county
study area, or ACC via home visits.
• Self-reported interview data were collected at intake,
3, 6, and 9 months post-residential discharge.
The effect of assertive continuing care on continuing care linkage, adherence and abstinence following residential
treatment for adolescents with substance use disorders. Godley, M., et al. Addiction, 2006, 102, 81-93.
Assertive Continuing Care
Results
• ACC led to significantly greater continuing care
linkage and retention and longer term abstinence from
marijuana.
• ACC resulted in significantly better adherence to
continuing care criteria which, in turn, predicted
superior early abstinence.
The effect of assertive continuing care on continuing care linkage, adherence and abstinence following residential
treatment for adolescents with substance use disorders. Godley, M., et al. Addiction, 2006, 102, 81-93.
Assertive Continuing Care
Conclusions
• ACC appears to be an effective alternative to UCC for
linking, retaining and increasing adherence to
continuing care
The effect of assertive continuing care on continuing care linkage, adherence and abstinence following residential
treatment for adolescents with substance use disorders. Godley, M., et al. Addiction, 2006, 102, 81-93.
Telephone-Based Continuing Care
Overview of Model
• Potential to promote better long-term engagement and
participation because:
– Convenient for client
– Promotes “self-management”
– Reduces stigma of weekly trips to the treatment
program
– Individualized attention
– Can be automated (Helzer, Searles et al.)
– Lower costs of ongoing care (face-2-face care)
Telephone-Based Continuing Care
Study Overview (McKay et al, 2005)
• Study sought to compare telephone-based continuing care
with 2 more intensive face-to-face continuing care
interventions.
• Alcohol- and/or cocaine-dependent patients (N = 359) who
completed a 4-week intensive outpatient program.
• A randomized 3-group clinical trial with a 2-year followup was conducted at 1 community-based and 1 Veterans
Affairs medical center facility and 2 outpatient substance
abuse treatment programs.
The Effectiveness of Telephone-Based Continuing Care for Alcohol and Cocaine Dependence.
McKay, J. et al. Archives of General Psychiatry, 2005, 62, 199-207.
Telephone-Based Continuing Care
Study Overview
• Three 12-week continuing care treatments: weekly
telephone-based monitoring and brief counseling
contacts combined with weekly supportive group
sessions in the first 4 weeks (TEL), twice-weekly
cognitive-behavioral relapse prevention (RP), and
twice-weekly standard group counseling (STND).
The Effectiveness of Telephone-Based Continuing Care for Alcohol and Cocaine Dependence.
McKay, J. et al. Archives of General Psychiatry, 2005, 62, 199-207.
Telephone-Based Continuing Care
Results
• Participants in TEL had higher rates of total abstinence
over the follow-up than those in STND (P<.05). In
alcohol-dependent participants, 24-month glutamyltransferase levels were lower in TEL than in RP
(P = .005). In cocaine-dependent participants, there was a
significant group x time interaction (P = .03) in which the
rate of cocaine-positive urine samples increased more
rapidly in RP as compared with TEL.
The Effectiveness of Telephone-Based Continuing Care for Alcohol and Cocaine Dependence.
McKay, J. et al. Archives of General Psychiatry, 2005, 62, 199-207.
Telephone-Based Continuing Care
Results
• Participants with high scores on a composite risk
indicator, based on co-occurring alcohol and cocaine
dependence and poor progress toward achieving
intensive outpatient program goals, had better total
abstinence outcomes up to 21 months if they received
STND rather than TEL, whereas those with lower
scores had higher abstinence rates in TEL than in
STND (P = .04).
The Effectiveness of Telephone-Based Continuing Care for Alcohol and Cocaine Dependence.
McKay, J. et al. Archives of General Psychiatry, 2005, 62, 199-207.
Telephone-Based Continuing Care
Study Overview (Farabee et al, 2008)
• Seeks to examine the impact of 4 telephone support
interventions to promote abstinence and increase aftercare
attendance among stimulant users (N=300).
• Telephone conditions consist of 7 calls conducted 1, 2, 4,
6, 8, 10, and 12 weeks following outpatient treatment
discharge. Research assessments are conducted at
baseline, and 3 and 12 months later.
• Subjects were randomized to 1 of 4 call conditions
(structured vs. directive), or a control group (no telephone
support).
Preliminary Results Examining The Impact of Telephone Support on Stimulant Recovery.
Farabee, et al. Presented at CPDD 2008.
Telephone-Based Continuing Care
Preliminary Conclusions
• Analysis of 145 subjects indicated assignment to any
of the “call” conditions (combined as a single group to
maximize statistical power) was associated with
positive trends regarding drug avoidance activities.
Preliminary Results Examining The Impact of Telephone Support on Stimulant Recovery.
Farabee, et al. Presented at CPDD 2008.
Recovery Coaching
• San Mateo Pilot Project
– High severity patient group with co-occurring
psychiatric disorders.
– Funded via a capitation payment arrangement
– “Recovery Coach” serves as the case manager,
continuing care manager, problem solver,
counselor, patient advocate. Primary role is to
maintain contact with patient and sustain their
involvement in recovery activities.
EnCAL Recovery Centers
Pilot Overview (Rawson et al, 2010)
• Site Visits were conducted by UCLA to better characterize
recovery centers within San Bernardino and Mariposa
counties.
• Recovery centers are funded to provide a range of recovery
services within the County AOD system.
• Cost-free services include self help meetings, life skills,
employment and educational support, sober activities, peer
support, informal recovery monitoring by staff members
and encouragement to engage in an initial phase of, or
return to, treatment, if needed.
Evaluation Services to Enhance the Data Management System in California (EnCAL): Fiscal
Year One Reports, Rawson et al, 2010
EnCAL Recovery Centers
Results
• Counties have long recognized the importance of recovery
support services (RSS) provided by recovery centers,
which extend outside of a formal treatment system.
• Lack of clear guidelines on RSS measurement may result
in data collection procedures that are not standardized.
• Pilot testing to 1) measure RSSs using established
measures within the literature and 2) determine the
feasibility of pilot data collection efforts is needed.
Evaluation Services to Enhance the Data Management System in California (EnCAL): Fiscal
Year One Reports, Rawson et al, 2010
•Thanks for your attention