Exploring the recovery process: Patterns, supports, challenges and future directions

1. Exploring the recovery process: Patterns, supports, challenges and future directions Alexandre B. Laudet Presented at the Seminar Series of the Division of Epidemiology, Services and Prevention Research (DESPR) National Institute on Drug Abuse (NIDA) April 20, 2005 Center for the Study of Addiction and RecoveryNational Development and Research Institutes, Inc. Correspondence: laudet@ndri.org

2. In collaboration with… • Co-Investigators: William L. White, Chestnut//Lighthouse Gordon Storey, Self-Help Addiction Resource Center (SHARC) • Statistician: Keith Morgen, NDRI • Operations: Virginia Stanick, and Marie Marthol, NDRI • Field: Jeffrey Becker, Wanda Bonilla, Nadina Correa, Una Cruz, Doug Goldsmith, , Myrta Hernandez, Yolanda Jones, Vanessa Rodriguez, Scott Smith, Luis Torres, NDRI • Design: Evette McCoy, NDRI

3. Background This presentation draws on prospective and retrospective findings from three NIDA-F studies using both quantitative and qualitative methods to explore the recovery experience over time as well as factors that promote and hinder the process. The studies were/are conducted among inner-city participants in New York City (details in handouts): • Pathways to long-term abstinence: Self-help processes, R01DA14409 • Twelve-step as aftercare: predictors and effectiveness, R01DA015133- • Referral to self-help: Clients’ and clinicians’ views, R03 DA13432

4. Pathways Study Sample (N = 354):Summary (see handouts) • Primarily members of inner-city ethnic, underserved minorities • Long & severe history of (primarily) crack and/or heroin use • Almost all are polysubstance users • Self-identified as ‘in recovery’ from one month to 10+ years • 30% HepC+ and 22% HIV+ • Almost all have used formal addiction treatment services and 12-step fellowships

5. Key Points • Need to make recovery a bona fide topic of research • Need to adopt long-term ‘career’ perspective • Need to identify multiplicity of recovery experiences, paths and chronological patterns (stages) and their determinants: • Recovery challenges, resources and unmet needs associated with the initiation, consolidation and maintenance of recovery

6. Why study the recovery process?

7. Why study the recovery process? • The prevalent view of addiction is that it is, for many, a lifelong ‘chronic’ disorder • However, stable recovery is a reality for millions of people • We know a great deal about active addiction patterns - there are large databases about lifetime, past year and past month substance use • We know about the process of recovery initiation through treatment evaluation studies • “Looking at treatment to understand recovery is like looking at birth to understand life” (Bill White)

8. Why study the recovery process? [2] • Recovery from a chronic disorder is process unfolding over time • We know little about temporal patterns of recovery over time or about predictors of long-term recovery (recovery consolidation and maintenance) • We know virtually nothing about the size or profile of the recovering community in the US • Worse, we know little about how recovering persons achieve or maintain their status over time • The drug field lags far behind the alcoholism field where several long-term and prevalence estimates of recovery have been conducted (e.g., Vaillant as well as Dawson 2005) - although more is needed.

9. Why study the recovery process? [3] • Active addiction has multiple, high costs to the individual and to society (ref. High HIV+ and HepC+ rates) • Understanding the recovery process and its determinants: • Inform program development and service delivery • Inform about needed supports and resources for the recovery community • Learning from the experiences of the recovering community can contribute to: • Give hope to active addicts and their family • Counterbalance the stigma of active addiction that leads to discrimination for recovering persons –e.g., in the work place

10. “One of the great surprises of longitudinal research is that you discover that people do recover” George Vaillant

11. What does ‘Recovery’ mean?

12. Public’s Perception Of “In Recovery”From Faces & Voices of Recovery – April 2004/Hart Research and Coldwater Corporation [National Random phone survey N = 801] When you hear the word “recovery, as in “This person is in recovery from an addiction,” what does “recovery” mean? Person is free from addiction/no longer uses D&A Person is trying to stop using D&A Person has been damaged by D&A Person has mental illness

13. Pathways Participants Recovery definition

14. Recovery definition: so what? • While the recovery community largely defines ‘recovery’ as the achievement of drug-free status, two-thirds of the the general public defines it as an attempt to become drug-free (can it be achieved?)… • This suggests that more work needs to be done to inform the public that achievingdrug-free recovery is a reality

15. Recovery patterns • Few long-term studies on recovery (<2 yrs) • Most conducted among alcohol-dependent persons (e.g. Vaillant) • Findings suggest that although the course of recovery varies across individuals, the likelihood of sustained recovery increases over time (I.e., the risk of relapse decreases over time)

16. Sustained drug-free recovery at F1 as a function of baseline recovery stage (N = 287)Pathways participants

17. Recovery patterns • Evidence that the risk of relapse remains, even after several years of abstinence…. • We examined retrospective recovery patterns among Pathways participants

18. Pathways to Long-Term AbstinenceRelapse History(n=354) Since starting regular drug use, did you ever have one or more period (s) of complete abstinence of one month or longer followed by return to active addiction?

19. Relapse History Number of clean periods followed by return to active addictionb Over 50% reported 4 or more abstinent periods followed by return to active addiction Range 1 to 90 Mean = 7.56; Std dev= 10.6 bAmong those who report one or more such periods: N=248- 5 “don’t know”

20. Length of longest ‘clean’ period before return to active addictionb 50% had one or more clean periods of one year or longer- 28% had one of 3 years or longer before slip/relapse Ranges= 1 to 120 Mean = 23.6 Std dev= 27.9 BAmong those who report one or more such periods: N=253

21. Length of relapse after longest clean period b 63% of respondents say relapse lasted over one year Range = > one month to 16 yrs Mean =36.3; Std dev= 49.3 b Among those who report one or more such periods: N=253

22. Relapse patterns: Relevance • One quarter of pathways participants are HIV+, 30% HepC+ • Increased likelihood of risky behaviors (e.g., unprotected sex, multiple partners) during active addiction • NEED TO ELUCIDATE BARRIERS TO SUSTAINED RECOVERY AND SUCCESFUL STRATEGIES TO SUSTAIN RECOVERY

23. Relapse after Recoveryb What got you back to using? Top answers (<10%) B Among those who report one or more such periods: N=253

24. Relapse after longest clean periodb Lessons learnt Top answers (<10%) B Among those who report one or more such periods: N=253

25. Strategies to deal with recovery challengesPathways participantscSeeking support and staying focused CAmong those who report a challenge

26. Recovery patterns summary • The risk of relapse remains well into the recovery process • Stress, exposure to triggers, temptations/urges, and belief that one can control drug use are recovery challenges and key factors in return to active addiction • Making recovery a priority, staying focused on recovery and seeking support are identified as helpful strategies

27. Recovery Capital

28. Recovery Capital • Recovery capital refers to the amount and quality of Internal and external resources that one can bring to bear to initiate and sustain recovery from addiction • A number of factors have been identified as predictors of recovery in short-term studies and constitute recovery capital • They include: • Cognitive recovery readiness • Participation in 12-step fellowships • Faith/spirituality/life meaning

29. Recovery Capital Cognitive recovery readiness

30. Cognitive recovery readiness • Cognitive domains associated with enhanced recovery outcomes in process research include: • Generic processes common to several addiction treatment orientations such as drug abstinence self-efficacy, motivation and coping; and • Processes that are unique to the disease (Minnesota) model: • Embracing the disease view of addiction as a lifelong disorder • Admitting powerlessness over drugs and alcohol, • Accepting the need for/believing in a Higher power, • Commitment to 12-step fellowships (intention to attend 12-step groups), and • identifying with others in recovery. • Increasing/higher levels of these cognitive processes found to be associated with better subsequent substance use outcomes.

31. Cognitive Recovery Readiness across Stages of Change

32. Cognitive Recovery Readiness as a function of help seeking careerPrior treatment here – same trend with prior 12-step attendance

33. So, Cognitive recovery readiness… • Increases over stages of change • Increases as a function of cumulative recovery help seeking (treatment and 12-step)

34. Recovery Capital 12-step fellowships

35. Background • In the United States, 12-step groups (e.g., Alcoholics and Narcotics Anonymous) are both the most prevalent types of self-help groups and the most common source of help sought by people with substance abuse problems. • Participation in 12-step groups during and after formal treatment associated with reduced rates of substance use • Concurrent use of 12-step and formal treatment has been shown to have additive effects

36. 12-step affiliation and sustained recovery Effectiveness: Twelve step affiliation (attendance and involvement) significantly associated with subsequent positive (sustained) recovery outcome…

37. Effectiveness: Sustained abstinent recovery at F1 as a function of baseline level of 12-step attendance and affiliation

38. 12-step attendance: Patterns and attrition

39. 12-step Attendance patternsAftercare participants (N = 314)

40. 12-step attrition: Ever dropped out? Since you fist started attending, have you ever stopped attended for one month or longer? (yes)

41. Perceived helpfulness and benefits of 12-step groups

42. Attitudes about 12-step among Drug Treatment patients e eScale range from 0 to 10

43. Reasons for 12-step attendancef ,g Famong ‘ever’ attenders; gAdd to < 100% because up to 3 answers were coded

44. Quandary: 12-step attrition and non-affiliation • 12-step fellowships generally viewed as helpful and beneficial to recovery • Yet, some never attend and many disaffiliate over time • One of the most important tasks for clinicians is to foster stable engagement in 12-step groups to facilitate patients’ transition into the post-treatment phase of recovery. • What are some of the reasons why substance users do not attend/leave 12-step?

45. Obstacles to 12-step affiliation and reasons for non-attendance

46. Why did you stop attending 12-step?(longest interrupted period)g GAdd to < 100% because up to 3 answers were coded

47. Observation… • Reasons cited for not attending 12-step groups mirror the lessons learnt from relapse and helpful strategies to recover: • Don’t want to stop vs. make recovery a priority • Can do it on my own vs. seek support • THIS SUGGESTS THAT MOTIVATION AND ACCEPTING NEED FOR/SEEKING SUPPORT FOR RECOVERY ARE CRITICAL

48. Recovery Capital Spirituality, Faith and Life meaning

49. Baseline Spirituality, Religiosity, Life meaning and Recovery @ F1

50. Pathways PilotSpirituality and religion as Recovery support (N=52) Describe any religious/spiritual experience/ support that you have had as a significant part of your recoveryh hAdds up to < 100% because up to 3 answers were coded