Recovery Management: History, Science

1
Recovery Management History, Science
Changes in Clinicial Practices

• William L. White, M.A.
• ROSC Symposium
• Atlanta, GA July 21-22

2
Presentation Goals

• 1. Highlight the emergence of recovery as an
  organizing paradigm for the addiction treatment
  field
• 2. Outline how frontline service practices are
  changing as systems of care local addiction
  treatment programs shift from an acute care (AC)
  model of intervention to a model of sustained
  recovery management (RM)

3
Perspective

• 40 years in treatment field
• Work in addictions research institute for past 22
  years
• Consultant to pioneer ROSC/RM implementation
  sites, e.g., CT and Philadelphia
• Work with recovery community organizations on
  development of P-BRSS via RCSP ATR sites,
  e.g., Recovery Consultants of Atlanta

4
A Recovery Revolution?

• Growth Diversification of American Communities
  of Recovery
• Recovery Community Institution Building
• A New Recovery Advocacy Movement
• Calls to Reconnect Treatment to the More Enduring
  Process of Personal/Family Recovery
• Shift from Pathology and Intervention Paradigms
  to a Recovery Paradigm
• White, 2004, 2005, 2006, 2007, in press

5
Recovery Community Building

• Growth and diversification of recovery mutual aid
  groups
• Recovery Community Organizations
• Recovery Homes
• Recovery Schools
• Recovery Industries
• Recovery Ministries/Churches
• Cultural Development Source White, 2008, 2009

6
Science New Recovery Support Institutions

• There is a growing body of evidence that
  enmeshing clients with high problem severity and
  low recovery capital within sober living
  communities can dramatically enhance long-term
  recovery outcomes. (Jason,Davis, Ferrari
  Bishop,2001), e.g. Oxford House 50 less
  relapse, twice monthly income, 1/3 incarceration

7
Advocacy Vision Versus Reality
Recovery
Treatment
Recovery
TX
Vision 1963-1970
Reality 2009
8
Signs of a Paradigm Shift

• Science-based conceptualizations of addiction as
  a chronic disorder (Hser, et al, 1997 McLellan
  et al, 2000 Dennis Scott, 2007)
• Accumulation of systems performance data on
  limitations of acute care (AC) model of addiction
  treatment (White, 2008)
• Recovery as an organizing construct for
  behavioral health care policies programs (e.g.,
  IOM, 2006 CSATs RCSP ATR programs)
• Recovery-focused systems transformation efforts
  (Clark, 2007 Kirk, 2007 Evans, 2007)

9
Signs of a Paradigm Shift

• Calls for a recovery-focused research agenda
  (White, 2000 White Godley, 2007, White
  Chaney, 2009 White Schulstad, in press)
• A new and newly nuanced language, e.g., efforts
  to define recovery, recovery-oriented systems of
  care (ROSC), and recovery management (RM) (e.g.,
  Journal of Substance Abuse Treatment 23(3), 2007)

10
Recovery Research

• New Resources
• The Varieties of Recovery Experience (White
  Kurtz, 2006)
• Linking Addiction Treatment Communities of
  Recovery Support A Primer for Addiction
  Counselors Recovery Coaches (White Kurtz,
  2006)
• Peer Recovery Support History, Theory, Science
  Practice (White, 2009)

11
AOD PROBLEMS
Etiology
Pattern
Treatment
Recovery



12
Clinical Versus Community Populations

1. Higher personal vulnerability (e.g., family
   history, lower age of onset, victimization)
2. Higher severity (acuity chronicity)
3. Higher rates of co-morbidity
4. Greater personal and environmental obstacles to
   recovery
5. Lower recovery capital (personal assets / family
   and social supports)

13
Family History and ATOD Vulnerability

• Genetic Risks
• Problem Severity and Chronicity
• Breaking Intergenerational Cycles of ATOD
  Dependence (See White Chaney, 2009)

14
Age of Onset of Use Personal Vulnerability

• Risk of adult SUD
• Speed of problem development
• Problem severity
• Problem complexity (e.g., psychiatric
  co-morbidity)
• Treatment Prognosis
• Duration of addiction career
• Mortality (e.g., involvement in alcohol-related
  crash)

15
Traumagenic Factors

• Age of Onset
• Duration
• Number of Incidents Number of Perpetrators
• Relationship of Perpetrators to the Family
• Physical Violence
• Types of Abuse
• Response to Breaking Silence (Titus, et al, 2003)

16
Recovery Capital

• Recovery capital is the quantity and quality of
  internal and external resources that can be
  mobilized to initiate and sustain long-tern
  addiction recovery (Granfield and Cloud, 1999).

17
What is Recovery?

• Sustained Abstinence--Primary Drug
• Sustained Abstinence--No Drug Substitution
• Reduction of Drug use to Subclinical Levels
• Sustained Absence of Drug-related Problems
• Resolution of AOD Problems within the Umbrella of
  Global Health
• (White, 2008)

18
Emerging Definition

• Sobriety
• Global Health
• Citizenship
• Journal of Substance Abuse Treatment Special
  Issue 33(3), including Betty Ford Consensus
  Panel, 2008 White, 2008

19
Types of Recovery

• 1. Abstinence-based Recovery
• 2. Moderated Recovery/Resolution
• --Prevalence increases as problem severity
  declines
• 3. Medication-assisted Recovery
• White Kurtz, 2006

20
Medication Assisted Recovery

• Aversive Agents
• Disulfram (Antabuse)
• Maintenance Agents
• Methadone and LAAM
• Buprenorphine
• Anti-craving Agents
• Naltrexone (Revia) and Acamprosate

21
Medication and Recovery Status

• Emerging View
• formerly opioid-dependent individuals who take
  naltrexone, buprenorphine, or methadone as
  prescribed and are abstinent from alcohol and all
  other nonprescribed drugs would meet this
  definition of sobriety. 2008 Betty Ford
  Consensus Panel

22
Recovery Prevalence

• Studies of people meeting lifetime criteria for a
  DSM-IV Substance Use Disorder in community and
  treatment samples reveal that 58-60 eventually
  achieve sustained recovery (i.e., no dependence
  or abuse symptoms for the past year). (Kessler,
  1994 Dawson, 1996 Robins Regier, 1991 Dennis
  et al, 2005)

23
Depth of Recovery

• 1. Full Recovery
• 2. Partial Recovery
• 3. Amplified (Transcendent) Recovery

24
Styles of Recovery

• Interpersonal Style
• Acultural
• Bicultural
• Culturally Enmeshed
• Variations in Personal Identity
• Recovery Positive Identity
• Recovery Neutral Identity
• Recovery Negative Identity

25
4 Overlapping Styles of Recovery

• Professionally Assisted
• Solo (Natural) Recovery
• Affiliated Recovery
• Disengaged Recovery
• White Kurtz, 2006

26
Gender Factors In Recovery Initiation

• Pregnancy
• Parenthood
• Fear of Effects of AOD use on Children
• Fear of Losing Custody of Children
• Separating from an Addicted Partner
• (Chen and Kandell, 1998 Burman, 1997)

27
Family Recovery (Brown Lewis)

• While recovery alleviates many of the familys
  historical problems, this early period can also
  be referred to as the trauma of recovery a
  time of great change, uncertainty and turmoil.
• The unsafe, potentially out-of-control
  environment continues as the context for family
  life into the transition and early recovery
  stages...as long as 3-5 years.

28
Family Recovery Principles

• Family members may need support structures to
  serve as holding environments until a healthier
  family system can be constructed.
• Without such supports, personal recovery may
  produce family disintegration.
• This change process can last for 5-10 years.

29
Recovery-oriented Systems of Care

• Recovery-oriented systems of care (ROSC) are
  networks of formal and informal services
  developed and mobilized to sustain long-term
  recovery for individuals and families impacted by
  severe substance use disorders. The system in
  ROSC is not a treatment agency but a macro level
  organization of a community, a state or a nation.
  

30
Recovery Management

• Recovery management (RM) is a philosophical
  framework for organizing addiction treatment
  services to provide pre-recovery identification
  and engagement, recovery initiation and
  stabilization, long-term recovery maintenance,
  and quality of life enhancement for individuals
  and families affected by severe substance use
  disorders.

31
Recovery Management Stages of Recovery

1. Pre-recovery identification and engagement
   (recovery priming)
2. Recovery initiation and stabilization
3. Transition to successful recovery maintenance
4. Enhancement of quality of personal/family life in
   long-term recovery

32
Rhetoric Versus Reality

• 1. Policy statements for more than 200 years have
  referred to addiction as a chronic disorder.
• 2. Research data just reviewed supports that
  contention.
• 3. But weve never really believed it.
• 4. Addiction treated like it was a broken arm
  rather than a condition such as diabetes or heart
  disease requiring sustained monitoring and care.

33
Addiction/Chronic Illness
Addiction/Chronic Illness Compliance Rate () Relapse Rate ()
Alcohol 30-50 50
Opioid 30-50 40
Cocaine 30-50 45
Nicotine 30-50 70
Insulin Dependent Diabetes
Medication lt50 30-50
Diet and Foot Care lt50 30-50
Hypertension
Medication lt30 50-60
Diet lt30 50-60
Asthma
Medication lt30 60-80
OBrien CP, McLellan AT. Myths about the
Treatment of Addiction (1996). The Lancet, Volume
347(8996), 237-240.
34
Severe substance dependence and other chronic
illnesses

• Are influenced by multiple personal, family and
  environmental risk factors.
• Are influenced by voluntary choices that become
  potentially less voluntary over time via
  neurobiological changes in the brain.
• Have a prolonged course that varies from person
  to person.

35
Substance Use Careers Last for Decades
100
90
80
Percent in Recovery
70
Median duration of 27 years (IQR 18 to 30)
Years from first use to 1 years abstinence
60
50
40
30
20
10
0
30
25
20
15
10
5
0
Source Dennis et al 2005 (n1,271)
36
Most people who develop abuse/dependence Have
substance related problems for years
Once they have abuse or dependence, over half
will have 12 or more years of AOD problems
Source Dennis, Coleman, Scott Funk
forthcoming National Co morbidity Study
Replication
37
It Takes Decades and Multiple Episodes of
Treatment
100
90
80
Percent in Recovery
70
Median duration of 9 years and 3 to 4 episodes
of care
Years from first Tx to 1 years abstinence
60
50
40
30
20
10
0
25
20
15
10
5
0
Source Dennis et al 2005 (n1,271)
38
Severe substance dependence and other chronic
illnesses

• Are accompanied by risks of profound
  pathophysiology, disability and premature death.
  
• Have effective treatments, self-management
  protocols, peer support frameworks and similar
  remission rates, but no known cures. (White
  McLellan, 2008)

39
If we really believed addiction was a chronic
disorder, we would not

• Create expectation that full recovery should be
  achieved from a single Tx episode (Demoralization
  of clients/families, staff, policy makers,
  community)
• View prior Tx as indicative of poor prognosis
• Extrude clients for becoming symptomatic
  (confirming their diagnosis)

40
If we really believed addiction was a chronic
disorder, we would not

• Treat addiction in serial episodes of
  disconnected TX
• Relegate aftercare to an afterthought
• Terminate the service relationship following
  brief intervention

41
The Prevailing Acute Care Model

• An encapsulated set of specialized service
  activities (assess, admit, treat, discharge,
  terminate the service relationship).
• A professional expert drives the process.
• Services transpire over a short (and
  ever-shorter) period of time.
• Individual/family/community is given impression
  at discharge (graduation) that recovery is now
  self-sustainable without ongoing professional
  assistance (White McLellan, 2008).

42
Treatment (Acute Care Model) Works!

• Post-Tx remissions one-third, AOD use decreases
  by 87 following Tx, substance-related problems
  decrease by 60 following Tx (Miller, et al,
  2001).
• Lives of individuals and families transformed by
  addiction treatment.
• Treatment Works, BUT

43
AC RM Model Review

• Comparison on 10 key dimensions of service design
  and performance
• AC Model Vulnerability
• How RM Models are Addressing Each Area of
  Vulnerability

44
1. AC Model Vulnerability Attraction

• Only 10 of those needing treatment received it
  in 2002 (Substance Abuse and Mental Health
  Services Administration, 2003) only 25 will
  receive such services in their lifetime (Dawson,
  et al, 2005).

45
Why People Who Need it Dont Seek Treatment

• Perception of the Problem, e.g., isnt that bad.
• Perception of Self, e.g., should be able to
  handle this on my own.
• Perception of Treatment, e.g., ineffective,
  unaffordable, inaccessible or for losers
• Perception of Others, e.g., fear of stigma and
  discrimination
• Source Cunningham, et, al, 1993 Grant 1997

46
Coercion vs. Choice

• The majority of people who do enter treatment do
  so at late stages of problem severity/complexity
  and under external coercion (SAMHSA, 2002).
• The AC model does not voluntarily attract the
  majority of individuals who meet diagnostic
  criteria for a substance use disorder.

47
RM Model Strategy Attraction

• Recovery-focused anti-stigma campaigns, e.g.,
  Recovery is Everywhere campaign, Ann Arbor, MI
• Early screening brief intervention programs
• Assertive models of community outreach
• Non-stigmatized service sites, e.g., hospitals
  health clinics, workplace, schools, community
  centers
• Principle Earlier the screening, diagnosis Tx
  initiation, the better the prognosis for
  long-term recovery

48
2. AC Model VulnerabilityAccess Engagement

• Access to treatment is compromised by waiting
  lists (Little Hoover Commission, 2003).
• High waiting list dropout rates (25-50) (Hser,
  et al, 1998 Donovan et al, 2001).
• Special obstacles to treatment access for some
  populations (e.g., women) (White Hennessey,
  2007)

49
Weak Engagement Attrition

• Dropout rates between the call for an appointment
  at an addiction treatment agency and the first
  treatment session range from 50-64 (Gottheil,
  Sterling Weinstein, 1997).
• Nationally, more than half of clients admitted to
  addiction treatment do not successfully complete
  treatment (48 complete 29 leave against
  staff advice 12 are administratively discharged
  for various infractions 11 are transferred)
  (OAS/SAMHSA 2005).

50
High Extrusion as a Motivational Filter

• High AMA and AD rates constitute a form of
  creaming e.g., view that Those who really want
  it will stay.
• The reality those least likely to complete are
  not those who want it the least, but those who
  need it the mostthose with the most severe
  complex problems, the least recovery capital, and
  the most severely disrupted lives (Stark, 1992
  Meier et al, 2006).

51
RM Model Strategy

• Assertive waiting list management
• Streamlined intake
• Lowered thresholds of engagement
• Pain-based (push force) to hope-based
  (pull-force) motivational strategies
• Appointment prompts phone follow-up of missed
  appointments
• Institutional outreach for regular re-motivation
• Radically altered AD polices (White, 2008 White,
  et al, 2005)

52
Substance Use Careers are Longer, the Younger
the Age of First Use
100
90
21
80
Percent in Recovery
15-20
Age of 1st Use Groups
70
Years from first use to 1 years abstinence
60
under 15
50
40
30
20
plt.05 (different from 21)
10
0
30
25
20
15
10
5
0
Source Dennis et al 2005 (n1,271)
53
Substance Use Careers are Shorter the Sooner
People get to Treatment
100
0-9
90
80
10-19
Years to 1st Tx Groups
Percent in Recovery
70
Years from first use to 1 years abstinence
60
50
40
20
30
20
10
plt.05 (different from 20)
0
30
25
20
15
10
5
0
Source Dennis et al 2005 (n1,271)
54
Altered View of Motivation

• Motivation seen as important, but as an outcome
  of a service process, not a pre-condition for
  entry into treatment. A strong therapeutic
  relationship can overcome low motivation for
  treatment and recovery (Ilgen, et al, 2006).
• Motivation for change no longer seen as sole
  province of individual, but as a shared
  responsibility with the treatment team, family
  and community institutions (White, Boyle
  Loveland, 2003).

55
3. AC Model Vulnerability Assessment Tx
Planning

• Categorical
• Pathology-focused, e.g., problem list to
  treatment plan
• Unit of assessment is the individual
• Professionally-driven
• Intake function

56
RM Model Strategy Assessment Recovery Planning

• Global rather than categorical (e.g., ASI, GAIN)
• Strengths-based (emphasis on assessment of
  recovery capital) (Granfield Cloud, 1999)
• Greater emphasis on self-assessment versus
  professional diagnosis
• Scope of assessment includes individual, family
  and recovery environment
• Continual rather than intake activity
• Rapid transition from Tx plans to recovery plans
  (Borkman, 1998)

57
4. AC Model Vulnerability Service Elements

• Widespread use of approaches that lack scientific
  evidence for their efficacy and effectiveness (in
  spite of recent advances)
• Minimal individualization of care, e.g., reliance
  on going through the program
• Only superficial responsiveness to special needs,
  e.g., specialty appendages rather than
  system-wide changes

58
RM Model Strategy Service Elements

• Emphasis on evidence-based, evidence-informed
  promising practices
• High degree of individualization, e.g. from
  programs to service menus whose elements are
  uniquely combined, sequenced supplemented
• Emphasis on mainstream services that are
  gender-specific, culturally competent,
  developmental appropriate, and trauma-informed

59
5. AC Model Vulnerability Composition of
Service Team

• AC Model often uses medical (disease) metaphors
  but utilizes a service team made up almost
  exclusively of non-medical personnel.
• AC model uses a recovery rhetoric but
  representation of recovering people in Tx milieu
  via staff and volunteers has declined via
  professionalization.

60
RM Model Strategy Composition of Service Team

• Increased involvement of primary care physicians
• New service roles, e.g., recovery coaches
• Utilization of new service organizations, e.g.
  community recovery centers (White Kurtz, 2006
  Valentine, White Taylor, 2007)
• Renewed emphasis on volunteer programs, consumer
  councils/ alumni associations
• Inclusions of indigenous healers in
  multidisciplinary teams, e.g., faith community

61
Recovery Coach / Community Guide

• Knowledgeable of about indigenous and formal
  community resources
• Capable of engaging the difficult-to-engage
  person
• Skilled at leading people into relationship with
  a recovering community
• Skilled at sustaining long-term recovery support
  relationships
• Skilled at organizing resources where none exist

62
The Recovery Coach / Community Guide

• Sees possibilities where others see only
  problems.
• Is personally connected to the communities
  within the community
• Can make things happen because they are trusted
  within these communities.
• Believes the community is a reservoir of
  untapped hospitality
• Knows an individuals engagement with the
  community begins when the guide leaves.
• (McKnight, 1995)

63
6. AC Model Vulnerability Locus of Service
Delivery

• Institution-based
• Weak understanding of physical and cultural
  contexts in which people are attempting to
  initiate recovery
• AC Model question How do we get the individual
  into treatment--get them from their world to our
  world?

64
RM StrategyLocus of Service Delivery

• Home-, neighborhood- community-based
• RM question How do we nest recovery in the
  natural environment of this individual or create
  an alternative recovery-conducive environment?
• Healing Forest metaphor concept of treating
  the community

65
7. AC Model Vulnerability Service Dose and
Duration

• One of the best predictors of treatment outcome
  is service dose (Simpson, et al, 1999). Many of
  those who complete treatment receive less than
  the optimum dose of treatment recommended by the
  National Institute on Drug Abuse (NIDA, 1999
  SAMHSA, 2002)

66
AC Model Vulnerability Frequency of Discharge,
Relapse, Re-admission

• The majority of people completing addiction
  treatment resume AOD use in the year following
  treatment (Wilbourne Miller, 2002).
• Of those who consume alcohol and other drugs
  following discharge from addiction treatment, 80
  do so within 90 days of discharge (Hubbard,
  Flynn, Craddock, Fletcher, 2001).
•  

67
Recovery/Relapse Patterns Over Twelve Months
68
Clinical Research(Treatment Outcome Studies)

• Sustained symptom suppression
• Symptom continuation (no measurable effect of
  treatment)
• Early suppression followed by clinical
  deterioration
• Early deterioration followed by sustained symptom
  suppression
• Cycles of suppression and deterioration

69
Fragility of Early Recovery

• Individuals leaving addiction treatment are
  fragilely balanced between recovery and
  re-addiction in the hours, days, weeks, months,
  and years following discharge (Scott, et al,
  2005).
• Recovery and re-addiction decisions are being
  made at a time that we have disengaged from their
  lives, but that many sources of recovery sabotage
  are present.

70
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery (Pathway Adults)

Over half change status annually

Incarcerated

(37 stable)
In the

In Recovery
Community

(58 stable)
Using


(53 stable)






In Treatment

(21 stable)

Source Scott, Dennis, Foss (2005)
71
AC Model Vulnerability Failure to Manage
Addiction/Tx/Recovery Careers

• Most persons treated for substance dependence who
  achieve a year of stable recovery do so after
  multiple episodes of treatment over a span of
  years (Anglin, et al, 1997 Dennis, Scott,
  Hristova, 2002).

72
AC Model Vulnerability Timing of Recovery
Stability

• Durability of alcoholism recovery (the point at
  which risk of future lifetime relapse drops below
  15) is not reached until 4-5 years of remission
  (Jin, et al, 1998).
• 20-25 of narcotic addicts who achieve five or
  more years of abstinence later return to opiate
  use (Simpson Marsh, 1986 Hser et al, 2001).

73
Reminder Fragility of Family Recovery

• While recovery alleviates many of the familys
  historical problems, this early period can also
  be referred to as the trauma of recovery a
  time of great change, uncertainty and turmoil.
• The unsafe, potentially out-of-control
  environment continues as the context for family
  life into the transition and early recovery
  stages...as long as 3-5 years.
• Source Brown Lewis, 1999

74
Aftercare as an Afterthought

• Post-discharge continuing care can enhance
  recovery outcomes (Johnson Herringer, 1993
  Godley, et al, 2001 Dennis, et al, 2003).
• But only 1 in 5 (McKay, 2001) to 1 in 10 (OAS,
  SAMHSA, 2005) adult clients receive such care
  (McKay, 2001) and only 36 of adolescents receive
  any continuing care (Godley,et al, 2001)

75
AC Treatment as the New Revolving Door

• Of those admitted to the U.S. public treatment
  system in 2003, 64 were re-entering treatment
  including 23 accessing treatment the second
  time, 22 for the third or fourth time, and 19
  for the fifth or more time (OAS/SAMHSA, 2005).

76
RM Model Strategy Assertive Approaches to
Continuing Care

• Post-treatment monitoring support (recovery
  checkups)
• Stage-appropriate recovery education coaching
• Assertive linkage to communities of recovery
• If when needed, early re-intervention
  re-linkage to Tx and recovery support groups
• Focus not on service episode but managing the
  course of the disorder to achieve lasting
  recovery.

77
RM Model Strategy Assertive Approaches to
Continuing Care

• 1. Provided to all clients not just those who
  graduate
• 2. Responsibility for contact Shifts from
  client to the treatment organization/professional

78
RM Model Strategy Assertive Approaches to
Continuing Care

• 3. Timing Capitalizes on critical windows of
  vulnerability (first 30-90 days following Tx) and
  power of sustained monitoring (Recovery Checkups)
  
• 4. Intensity Ability to individualize frequency
  and intensity of contact based on clinical data

79
RM Model Strategy Assertive Approaches to
Continuing Care

• 5. Duration Continuity of contact over time
  with a primary recovery support specialist for up
  to 5 years
• 6. Location Community-based versus clinic-based
• 7. Staffing May be provided in a professional
  or peer-based delivery format
• 8. Technology Increased use of telephone-
  Internet-based support services

80
Post-Treatment Recovery Coaching

• Encourage Self-monitoring
• Recovery Checkups
• Feedback
• Stage-Appropriate Recovery Education
• Resource Linkage (Indigenous)
• Early Re-intervention (Treatment)
• Re-engagement and Recovery Priming Following
  Broken Contact

81
Dennis, Scott Funk Chicago Adult Study (2003)

• Effect of Recovery Management Checkups on Cycle
• Sample 448 individuals randomly assigned to
  receive over 2 yrs either quarterly assessment
  interviews or quarterly recovery management
  (assessment with re-intervention and linkage to
  Tx)

82
Recovery Management Checkups

• Study Findings
• Those assigned to RMC more likely to return to Tx
  sooner, spend more days in Tx, less likely to
  be in need of Tx at 24 months

83
Godley, Godley, Dennis, et al, Adolescent Study
(2002)

• Sample 114 adolescents discharged from IP Tx
  randomly assigned to aftercare as usual or
  assertive continuing care (ACC)
• ACC Intervention Home visits, sessions for
  adolescents, parents and joint sessions, case
  management

84
Effects of Assertive Continuing Care

• Findings at 3 months
• 1. ACC group had a higher engagement/retention
  rate (94)
• 2. ACC group averaged more than twice the
  continuing care sessions as the control group
• 3. ACC group showed lower relapse rates for
  alcohol and cannabis days to first use longer in
  ACC group members who did use

85
8. AC Model Vulnerability Relationship with
Recovery Communities

• Participation in peer-based recovery support
  groups (AA/NA, etc.) is associated with improved
  recovery outcomes (Humphreys et al, 2004).
• This finding is offset by low Tx to community
  affiliation rates and high (35-68) attrition in
  participation rates in the year following
  discharge (Makela, et al, 1996 Emrick, 1989)

86
Passive/Active Linkage

• Active linkage (direct connection to mutual aid
  during treatment) can increase affiliation rates
  (Weiss, et al 2000),
• But studies reveal most referrals from treatment
  to mutual aid are passive variety (verbal
  suggestion only) (Humphreys, et al 2004)

87
Mutual Aid and Special Populations

• Early Criticisms
• Women and people of color affiliate with AA/NA at
  the same rates as white men (Humphreys, 1994
  Kessler, et al, 1997 Winzelberg and Humphreys,
  1999)
• Over time, participation in AA for African
  Americans and Hispanics decreases (Tonigan, et
  al, 1998) This may reflect a transfer of
  recovery maintenance to indigenous institutions.

88
RM Model Strategy

• Staff volunteers knowledgeable of multiple
  pathways/styles of long-term recovery, local
  recovery community resources and Online recovery
  support meetings and related services
• (White Kurtz, 2006)
• Direct relationship with H I committees and
  comparable service structures
• Recovery coaches provide assertive linkages to
  support groups and larger communities of recovery

89
9. AC Model Service Relationship

• Dominator-Expert Model Recovery is based on
  relationships that are hierarchical,
  time-limited, transient and commercialized.

90
RM ModelService Relationship

• Partnership Model Recovery is based on
  imbedding the client/family in recovery
  supportive relationships that are natural,
  reciprocal, enduring, and non-commercialized.
• RM is focused on continuity of contact in a
  recovery supportive service relationship over
  time comparable to role of primary physician.
• --Will require stabilization of fields
  workforce
• Philosophy of Choice / Consultation Role

91
10. AC Model VulnerabilityEvaluation

• Historical focus on measurement of short-term
  outcomes of a single episode of care at a single
  point in time following treatment outcome is
  measured by
• pathology reduction.

92
RM Model StrategyEvaluation

• Focus on effect of interventions on
  addiction/treatment/recovery careers at multiple
  points in time (McLellan, 2002)
• Focus on long-term recovery processes and quality
  of life in recovery.
• Greater involvement of clients, families
  community elders in design, conduct and
  interpretation of outcome studies (White
  Sanders, 2008).
• Search for potent service combinations and
  sequences.

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Closing Thoughts

• 1. ROSC and RM represent not a refinement of
  modern addiction treatment, but a fundamental
  redesign of such treatment.
• 2. Overselling what the AC model can achieve to
  policy makers and the public risks a backlash and
  the revocation of addiction treatments
  probationary status as a cultural institution.

94
Closing Thoughts

• 3. It will take years to transform addiction
  treatment from an AC model of intervention to a
  RM model of sustained recovery support.
• 4. That process will require replicating across
  the country what is already underway in the City
  of Philadelphia aligning concepts, contexts
  (infrastructure, policies and system-wide
  relationships) and service practices to support
  long-term recovery.