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Recovery Management: History, Science

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Recovery Management: History, Science & Changes in Clinicial Practices William L. White, M.A. ROSC Symposium Atlanta, GA July 21-22 Presentation Goals 1. – PowerPoint PPT presentation

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Title: 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 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 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 Strategy Locus 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 Model Service 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 Vulnerability Evaluation
  • 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 Strategy Evaluation
  • 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.

93
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.
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