Recovery Management: History, Science & Changes in Clinicial Practices

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; CSAT’s 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 • Higher personal vulnerability (e.g., family history, lower age of onset, victimization) • Higher severity (acuity & chronicity) • Higher rates of co-morbidity • Greater personal and environmental obstacles to recovery • 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 family’s 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 • Pre-recovery identification and engagement (recovery priming) • Recovery initiation and stabilization • Transition to successful recovery maintenance • 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 we’ve 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 O’Brien 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% 0 5 10 15 20 25 30 Source: Dennis et al 2005 (n=1,271)

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% 0 5 10 15 20 25 Source: Dennis et al 2005 (n=1,271)

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 Don’t Seek Treatment • Perception of the Problem, e.g., isn’t 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 Vulnerability:Access & 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 most—those with the most severe & complex problems, the least recovery capital, and the most severely disrupted lives (Stark, 1992; Meier et al, 2006).