Transcript Slide 1

ADDICTION RECOVERY
Where are we going? How do we get there?
Lessons from the recovery experience for service development
Alexandre B. Laudet, Ph.D
Institute for Research, Education, and Training in Addictions
Tampa, FL ● August 2-4, 2010
ACT ONE
WHY ARE WE HERE TODAY?
Why are we here today?
For many, substance use disorders are chronic (on par with diabetes, asthma etc…)
Addiction can not be cured but it can be arrested or managed
For some, it may require ongoing care of various intensities over time (e.g.,
intensive services, stepped down or after care, recovery checkups, 12-step)
HOW ARE WE TREATING ADDICTION?
Acute model of care (assess, treat, discharge)
Focused on symptoms, not on promoting wellness
Short-term episodes of intensive care are ill-suited to manage a chronic
condition:
High attrition rate - e.g., 60% attrition from outpatient nationwide
Few achieve abstinence during treatment
High relapse rates after treatment –50– 60% within 6 months following
treatment
Costly cycling through multiple episodes of care – e.g. in one study in
NYC, 80% outpatient client report 1 or + previous episode, 50% >3
People don’t get better, some die, families and communities suffer
A wind of change…
Recovery is more than abstinence from alcohol and
drugs; it is about building a full and productive life in
the community. Our treatment systems must
reflect and help people achieve this broader
understanding of recovery. (Dr. W. Clark, 2007)
Recovery Oriented System of Care (ROSC)
Elements of Recovery-Oriented Systems
of Care
A ROSC is a coordinated network of community-based services and supports that is
person-centered and builds on the strengths and resilience of individuals, families,
and communities to achieve abstinence and improved health, wellness, and quality of
life for those with or at risk of alcohol and drug problems.
Person-centered
Family and other ally involvement
Individualized and comprehensive services
Systems anchored in the community
Continuity of care
Partnerships
Strength-based
Culturally responsive
Responsive to personal belief systems
Commitment to peer services
Include recovering people and families
Integrated services
System-wide educational and training
Ongoing monitoring and outreach
Outcomes-driven
Evidence-based
Adequately and flexibly funded
From W. Clark, CSAT, Generic ROSC talk
Paradigmatic shifts needed to implement ROSC
From intense episodes of acute specialty care to
multi-systems, person-centered continuum of
care
From addressing pathology to promoting global
health, wellness, and recovery
Recovery Oriented System of Care
THIS SOUNDS VERY GOOD
THIS MEANS BIG CHANGES (more PAPERWORK???)
HOW DO WE GET THERE?
NEED TO KNOW
1. What recovery means
2. What helps/hinders the process
3. How this can be translated into services and policy
 At the patient level
 At the program level
 At the system level
How much do we know about recovery?
Research has mirrored the service delivery paradigm
Focused on primary symptom as outcome
Focused on treatment populations
Short term studies mostly
As a result, we lack information on:
What ‘recovery’ means: abstinence + WHAT?
Long-term recovery paths, patterns and their predictors
Especially among persons who are not enrolled in treatment
How can we promote/support an outcome we have not
examined and poorly understand?
We need a science of recovery
to inform Recovery Oriented
Systems of Care
What will the science of recovery do?
Support the development, monitoring and evaluation of
ROSC at all 3 levels by answering:
1. Destination: Where are we going? Specifically what are
we trying to promote (what is recovery? long-term recovery)?
2. Roadmap: How do we get there? What to put in our
recovery-oriented services toolbox to best serve clients as their
needs change?
3. Are we there yet? How can we measure recovery
outcomes? (for service monitoring and quality improvement,
accountability)
Summary of key datasets
used in today’s presentation
NIDA funded studies conducted in NYC 2002 - 2009
Pathways: The community-based sample
Study funded to elucidate patterns and psychosocial predictors of stable
abstinence from drugs and alcohol use
Media recruited sample (N = 354) re-interviewed yearly 3 times: one-, twoand three year follow-up (83% retention of surviving BL cohort of 342)
Self-reported abstinence at baseline from one month to 10+ years
Primarily members of inner-city ethnic, underserved minorities
Long & severe history of (primarily) crack and/or heroin use
Almost all are polysubstance users
30% HepC+ and 22% HIV+
Almost all have used formal addiction treatment services and 12-step
fellowships
Pathways participants were classified by baseline
abstinence duration according to clinically
meaningful stages
Three+ yrs
27%
18 to 36 mo.
20%
< 6 mos. Drug
abstinent
27%
6 to 18 mos.
26%
Twelve-step as aftercare: The outpatient
treatment sample
Study funded to identify predictors, patterns and outcomes of 12 step
participation after outpatient
Recruited consecutive admissions at two publicly funded outpatient
programs
250 clients re-interviewed at treatment end (90% re-contact) who constitute
the prospective study cohort
Follow-up interviews 3-, 6- and 12-months post treatment end
Full dataset on 219 participants ( 87.6% retention) one year post discharge
Primarily members of inner-city ethnic, underserved minorities
Long & severe history of (primarily) crack and/or heroin use
Average of 5.8 previous treatment episodes
ACT TWO
WHERE DO WE NEED TO GO?
Recovery
Substance users try to quit because they want a
better life
To what extent was [item] a factor in your decision to stop using drugs this time?
“Not at all, a little, moderately,
very much, extremely” (N = 354)
Didn't like where life was
going/feared consequences
94%
Desire for a better life
93
Tired of the drug life
92
Didn't like what I was becoming
90
Weighing pros & cons of
continued use
86
Negative effects of drug use on
others
Laudet & White, 2004a
83
50
75
100
Does quitting use ‘lead’ to a better
life???
Benefits of recovery: Open-endeda
What, if anything, is/would be good about being in recovery?
RECOVERY = A BETTER LIFE
33%
ch ance
New life/2nd
Clear head
ment
Self-improve
tion/goals
Having direc
e
Better attitud
conditions
Better living
lth
l/mental hea
a
ic
s
y
h
p
r
e
tt
Be
life
Better family
ds
Having frien
23
23
18
17
16
16
13
11
0
a
5
Add to > 100% because up to 3 answers were coded
10
15
20
25
30
35
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
RECOVERY STAGE
Laudet, Morgen & White, Alc. Tx Q. 2006
3+ years
Recovery definitions
Recovery definitions
Recovery from alcohol and drug problems is a process of change
through which an individual achieves abstinence, improved
health, wellness, and quality of life. (CSAT, 2005 National
Recovery Summit)
Recovery from substance dependence is a voluntarily maintained
lifestyle characterized by sobriety, personal health, and
citizenship. (Betty Ford Institute, 2007)
Let’s ask the REAL experts…
People in recovery!
Let’s ask the REAL
experts…people in recovery!
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
a
10
20
30
Add to > 100% because up to 3 answers were coded; Laudet, JSAT, 2007
40
50
My definition of recovery is life… ‘Cause I
didn’t have no life before I got into recovery
Pathways study participant H.W. 42 years old Af-Am male
Laudet, JSAT, 2007
Recovery is a process, not an endpoint
“Recovery is a continuous process that never ends”
96.8%
Agree/Strongly
agree
3.2%
Disagree/Strongly
disagree
0
Laudet, JSAT, 2007
20
40
60
80
100
Relevance to ROSC
Recovery is a reality
Recovery is a Process of Change and Growth
Recovery is Sobriety + improved quality of life
Destination Recovery:
Few Direct flights
FOR TOO MANY PEOPLE,
ADDICTION IS A CHRONIC
RELAPSING CONDITION…
That’s where ROSC comes in…
Addiction career Number of abstinent periods one month
or longer followed by return to drug use prior to current abstinence*
50% reported 4 or more abstinent periods
followed by return to active addiction
One
17%
20 & over
10%
Ten to 19
17%
Two
22%
Six to nine
7%
Three
11%
Four to five
16%
*Outside of controlled environment, among those who report one or more such periods: 71% N=248
Laudet & White 2004b
Relevance to ROSC
Continuity of services and supports
ACT THREE
What’s wrong with the current model?
NYC Outpatient treatment outcome
Completed
40%
Left before
completion
60%
Completion rate on par w/ national average of 36% for outpatient modalities
Laudet, Stanick, & Sands, JSAT 2009
% Returned to substance use in the post-treatment
year as a function of discharge status
Drop-outs were 2.8 times more likely to return to drug use in the year after
services ended than were treatment completers (95%CI =1.86-4.23, p>.001)
100
90
80
92.6%
70
60
50
57.8%
40
30
20
10
0
Completed Left before
completion
Chi. Sq. 35.5, p = .0000
Stanick, Laudet & Sands, 2008
Treatment Career: Number of prior episodes
Over half of outpatient clients have had
3 or more previous episodes
Ten +
14%
None
21%
Five to nine
21%
One
15%
Three-four
17%
Laudet, Stanick & Sands, Eval Review, 2007
Two
12%
One third seek treatment again in the 12
months after leaving the index episode
No additional
treatment
69%
Laudet and Stanick, CPDD 2010
Additional treatment
31%
Reasons for leaving treatment: Qualitative analyses
What is the most important reason why you dropped out of the program?*
Dislike
program/staff/clients
31.6%
Tx interferes w/other
activity (e.g., job)
18.8
Using
12
Convenience (e.g.,
transport)
12
Family/personal issues
12
Do not want help
12
9.4
Finances
8.5
Not helpful
0
5
10
15
20
25
30
* Add to > 100% because up to 2 answers were coded; Laudet, Stanick, & Sands, JSAT 2009, 37:182-190
35
Minimizing attrition [1]
Is there anything the program could have done differently so that you
would have continued attending?
No
67%
Yes
33%
Laudet, Stanick, & Sands, JSAT 2009
Minimizing attrition [2]
What could have been done differently so that you would have continued
attending (among ‘yes’)
Greater flexibility
in scheduling
23%
Better
individualized
services
23%
Laudet, Stanick, & Sands, JSAT 2009
Practical
assistance
11%
Help with other
areas of
functioning
18%
Better, more
caring staff
25%
Substance use is but a symptom,
Promoting abstinence is not enough
Expectation of help
Overall, how much do you think your coming to this treatment
program will help you address your needs and priorities?
Not at all
1%
A little
4%
Quite a bit
24%
Very much
71%
Remember this? 33% of drop outs may have stayed longer if
they had help in other life areas …
Missed opportunities?
What could have been done differently so that you would have continued
attending (among ‘yes’)
Greater flexibility
in scheduling
23%
Better/more
caring staff
25%
Laudet, Stanick, & Sands, JSAT 2009
Practical
assistance
11%
Help with other
areas of
functioning
18%
Better
individualized
services
23%
Quality of life satisfaction
sustains abstinence…
Quality of life satisfaction predicts sustained
abstinence: Community based sample
DIET
Stop
drugs
Jeans fit better
HAPPIER
Want that
feeling
Want to
stay happy
Pass on Donut
SAY NO
TO DRUGS
Controlling for other relevant variables, baseline QOL satisfaction predicts
sustained abstinence one and two years later.
Association partially mediated by motivation for abstinence
Laudet, Becker & White, 2009, 44
“What worked for me is just the thought that I don’t wanna
go through that madness no more. … See, ‘cause if I was
to use again, I probably would lose everything”.
Pathways participant
Behavioral economics: Demand law
But what makes them happy???
Priorities @ outpatient admission
What are the priorities in your life right now? (N = 314)
Get/Stay clean
Get a job
Educ/Voc/Training
Abstinence is top goal
but not only goal!!!
Get kids back
Housing
Relation w.family
Get life together
Complete tx
0
10
20
30
40
50
Life priorities in recovery by abstinence duration
“What are the priorities your life right now?”
(N = 354)
Recovery
Employment
Relationships
< 6 mos.
Educ/training
6 - 18 mos.
18 - 36 mos.
Normal life
> 3 years
Family reunification
Housing
0
Laudet & White, JSAT 2009
10
20
30
40
50
60
Relevance to ROSC
Individualized and comprehensive services/supports
Multi-system Integrated services
ACT FOUR
With a little help from my friends…
Sources of support in long-term recovery
Pathways pilot (N = 52 CCAR members, median abstinence duration 12 yrs)
aith
f
/
y
t
i
itual
r
i
p
S
ily
Fam
ers
e
p
ring
e
v
o
Rec
use
o
p
S
gth
n
e
r
r st
e
n
n
/i
Self
nds
e
i
r
F
ns
a
i
c
i
Clin
53%
53
43
18
17
11
7
0
10
20
Laudet, Savage & Mahmood, J. Psychoactive Drugs, 2002
30
40
50
60
Lessons learned from Relapse
a
Top answers (<10%)
What if anything have you learned from the relapse experience?
21.8%
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18.7
18.3
15.1
11.5
10.3
Among those who report one or more such periods: N=253; Laudet & White, 2004b
Strategies to deal with relapse triggers:
Most cited = Seek support, stay focused on recovery
Distraction
6%
Seek help/support,
Talk about pb
44%
Stay focused
42%
C
Among those who report a challenge; Laudet & White 2004b
Meditate/pray
8%
Example of source of support and motivation:
Twelve-step fellowships
Role of continuous 12-step attendance on odds of
abstinence sustained for two years: Pathways study
8
8
6.25
5.7
4.5
4.5
4
0
Total
sample
Laudet & White 2006
Under 6 Six to 18 18 to 36
months months months
Three
years +
Relevance to ROSC
Draw on Support from peers, family
members, significant others, friends,
and the community
ACT FIVE
So what???
Translating Research into Recovery Oriented Systems
Recovery Oriented System of Care makes
Sense…
Based on the experience of people in treatment and in recovery, the
core elements of ROSC ‘make sense’
The transition to ROSC will
Take time
Take full commitment from the ‘system’ including payors
Take place gradually
Experience and success of ‘leader states/cities’ (e.g., CT, Philly, ) will
be invaluable
In the meantime, strive to ADOPT AS MANY ELEMENTS OF ROSC AS
BUDGET ALLOWS
Recovery Oriented System of Care makes Cents…
Mathematical simulation of the costs of methadone treatment over the lifetime
for an opiate dependent individual under the chronic vs. acute model of care:
‘We find that the benefit-cost ratio of treatment from our lifetime model (37.72)
exceeds the benefit-cost ratio from a static model (4.86)’ (Zarkin et al., 2005, p.
1133).
NOT CONVINCED YET???
The Connecticut experience* (statewide ROSC)
24% decrease in expenses
46% increase in number of people served statewide
62% decrease of acute care
40% increase in outpatient care
25% decrease in annual cost per client
14% lower cost with recovery support
* 2008 statewide data from Kirk, in press in Kelly and White
60
Let’s get to work!
Questions? Comments?
How can we help?
http://www.attcnetwork.org/regcenters/index_northeast.asp
www.ireta.org
Email: [email protected]