Addiction Careers and the opportunity for effective interventions

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Addiction Careers and the opportunity for
effective interventions

• Dr David Best
• Senior Lecturer in Addictions (UoB)
• Reader in Criminal Justice (UWS)

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Addiction Careers
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What Do Eminent International Experts Tell Us?

• Addiction is not self-curing. Left alone,
  addiction only gets worse, leading to total
  degradation, to prison, and ultimately to death
• Robert Dupont
• Director of NIDA
• 1993
• As with treatments for these other chronic
  medical conditions hypertension, diabetes,
  asthma, there is no cure for addiction
• OBrien and McLellan, The Lancet, 1996

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So What Do Clients Typically Get in Treatment

• Mean length of last session 46.6 minutes
• One hour and thirty-three minutes per month
• Or 18.6 hours per year
• Of which 10 minutes per session is therapeutic
• 4 hours of therapeutic activity per year

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Time spent (in minutes) in last drug working
session
Best et al (in press)
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What has gone wrong with structured day treatment
TARGETS
Quantity Over Quality
Morale collapse contagion
Methadone, wine welfare
Working in a tap factory
Methadone based treatment
Instrumental working
Models of chronic, relapsing condition
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Treatment WORKS!

• DARP
• TOPS
• DATOS
• NTORS
• DORIS
• But for whom .
• Is a public health and safety model compatible
  with a model for individual recovery?

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Drug Use Outcomes Residential
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The stages of an addiction or crime career

• Onset
• Escalation
• Persistence
• Desistance

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Sampson and Laubs Reformatory Sample followed
from 15 to 70
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Sampson and Laubs Reformatory Sample followed
from 15 to 70
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So what is unique about the careers perspective?

• It is generally a model of hope
• The Laub and Sampson model rejects a risk factors
  approach in favour of adult growth
• While recognising the chronic and relapsing
  nature of addiction, this is not seen as a life
  sentence
• Key concept of turning points
• Windows of opportunity for change
• The key turning points are psychological and
  social not biochemical
• Links to Whites concept of monocultural and
  bicultural social networks

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What do we mean by a turning point?

• Laub and Sampson (2004) follow-up study of
  adolescents from youth offending institutes
  followed up to the age of 70
• Key predictors of change were successful
  relationships and stable employment
• Debate is about structure or function what
  comes first?
• Treatment can act as a turning point if it
  provides a window of opportunity for change, and
  there are available resources to sustain and
  support that change in real-life settings
• White (2007) and the concept of recovery
  communities

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Social capital and the implications for treatment

• The sum of the resources, actual or virtual,
  that accrue to an individual or a group by virtue
  of possessing a durable network of more or less
  institutionalised relationships of mutual
  acquaintance and recognition (Bourdieu, 1992)
• Those who possess larger amounts of social
  capital, perhaps even independently of the
  intensity of use, will be likely candidates for
  less intrusive forms of treatment (Granfield and
  Cloud, 2001)

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Natural recovery

• Sobell, Campbell and Sobell (1996) reported rates
  of 75 and 77 recovery without formal help in
  drinkers in remission.
• Cunningham (2000) assessed recovery from a range
  of substances, and reported that the use of any
  formal treatment ranged from 43.1 for cannabis
  to 90.7 for heroin, with 59.7 of cocaine users
  seeking formal treatment at some point in their
  recovery journeys.
• Bloomqvist (1999) has argued that the allocation
  of resources and opportunities in life will shape
  the likelihood of recovery journeys and the
  options available to people.

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Stall and Biernackis (1986) three-stage model

• Finding the resolve to terminate the use of
  substances (often precipitated by avoidance
  experiences such as medical, CJ or financial
  problems)
• Making a public pronouncement to quit that
  strengthens ones resolve
• The development of approach-oriented assets such
  as social support, new relationships, increased
  self-confidence, identity change, and increased
  involvement in family, religion and education

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Personal and social capital linking
psychological and sociological models

• What are the resources at a persons disposal?
• What is their stake and commitment to the
  conventional values of society
• Laub and Sampson (2004) desistance predictors
• Attachment to a conventional person (spouse)
• Stable employment
• Transformation of personal identity
• Ageing
• Inter-personal skills
• Life and coping skills

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The recovery agenda

• Alexandre Laudet (2008)
• Understanding recovery and identifying factors
  that promote or hinder it will require a number
  of paradigm shifts for addiction professionals,
  including moving from an acute care model to a
  chronic or long-term approach, and shifting the
  focus of research and service provision from
  symptoms to wellness

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What are the aims of recovery research? (William
White, pers comm)

• shortening addiction careers
• extending recovery careers
• capitalizing on developmental opportunities for
  recovery initiation
• matching individuals to particular types of
  recovery support
• the styles and stages of long-term recovery to
  provide normative data for individuals, families
  and service workers

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The Scottish policy context

• A process through which an individual is enabled
  to move on from their problem drug use, towards a
  drug-free life as an active and contributing
  member of society
• The Road to Recovery (Scottish Govt, 2008)
• The report emphasises that one of the key aims is
  to bring about a shift in thinking

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Key principles of the Road to Recovery

• Recovery is the explicit aim of all services
• A range of appropriate treatment and
  rehabilitation services should be available in
  each locale
• Treatment must integrate effectively with a wide
  range of generic servicees
• There is a commitment to establishing a Drug
  Recovery Network and to build the capacity of
  advocacy services

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End Of Careers Study

• Sample of 187 former addicts (alcohol, cocaine
  and heroin) currently working in the addictions
  field, from total group of 228 former users
• 70 male
• Mean age 45 years
• 92 white
• Worked in the field for an average of 7 years
• Best et al (2008)

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What finally enabled participants to give up?
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What enabled people to maintain abstinence?
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Key qualitative themes

• Key role of social learning
• Need to complement recovery belief with recovery
  of esteem and learning of skills
• People may move through and beyond mutual aid
  groups
• Incompatibility of treatment and mutual aid
  pathways

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Recovery study in Birmingham and Glasgow
mapping the roads to recovery

• What are the support group options in each city
  for people achieving stable recovery?
• What are their routes to recovery?
• What are the key turning points in recovery
  journeys
• How does it differ for abstinent compared to
  maintained heroin users?
• What are the key policy implications?

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Preliminary Birmingham data

• Based on 20 members of DATUS Birmingham service
  users group who will be the peer interviewers
• Mean age 32.5 (range 24-43)
• 80 male, 80 single, 70 white British, 60 have
  children
• 1 homeless at interview BUT 90 lifetime
  homelessness
• 2 working full-time 1 part-time 6 doing
  voluntary work
• Only 10 have never had full-time jobs and have
  averaged 7.8 years in FT employment, but last
  worked on average at age 27

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Preliminary Birmingham data
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Preliminary Birmingham data

• 11 have ever attended NA, 2 other mutual aid
  groups
• 9 are in maintained recovery, 11 in abstinent
  recovery
• Markedly higher self-esteem and self-efficacy in
  the abstinent than the maintained groups
• Maintained group score significantly higher on
  QoL scale measuring health independence
• BUT no differences in depression, anxiety or
  heroin relapse anxiety

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Self-esteem and self-efficacy in treatment and
recovery populations
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Emerging qualitative themes

• Reasons for stopping include a fear of rock
  bottom (losing everything), maturing out (tired
  of lifestyle) and family factors (pregnancy, loss
  of children and relationships)
• Much support for 12 step, peer groups and day
  programmes
• Frequent aspiration to become a worker in the
  field, and to be a better parent and person

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Conclusion

• We have reached a tipping point as a field
• Policy makers and the public purse deserve
  better!
• The recovery agenda allows for local ownership
  but a different model of addiction
• Treatment should not really mean pharmaceuticals
  abstinence is only a staging post in the
  recovery journeys
• Maintenance has a key role to play but it only
  equates to recovery for a minority
• We need more evidence of recovery!