National Perspective & Future Directions

1. Recovery: National Perspective & Future Directions H. Westley Clark, MD, JD, MPH, CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration U.S. Department of Health and Human Services

2. SAMHSA’s and CSAT’s Mission and Future Directions • Recovery is at the center of the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) mission. • Fostering the development of recovery-oriented systems of care is a priority of the Center of Substance Abuse Treatment (CSAT).

3. Past Month Alcohol Use • Any Use: 52% (126 million) • Binge Use: 23% (55 million) • Heavy Use: 7% (16 million) (Binge and Heavy Use estimates are similar to those in 2002, 2003, and 2004; Past month use increased from 50% in 2004) NSDUH 2005

4. Illicit Drug Use, by Age: 2002-2005 Percent Using in Past Month Age in Years + Difference between estimate and the 2005 estimate is statistically significant at the .05 level.

5. Non-medical Use of Prescription Drugs, Ages 12+: 2002-2005 Percent Using in Past Month + Difference between estimate and the 2005 estimate is statistically significant at the .05 level.

6. Source Where Psychotherapeutics Were Obtained for Most Recent Non-medical Use among Past Year Users Aged 12 or Older: 2005 Other Bought on Internet Drug Dealer/ Stranger 1 or More Doctors Bought/Took from Friend/ Relative Free from Friend/Relative Percent of Past Year Users

7. (5.2 million Adults) Substance Use Disorder Serious Psychological Distress General Population Survey (NSDUH) 2005 Co-Occurring Disorders 21.1 million Adults 24.6 million Adults 60% Drug Use Disorder Treatment Seeking Population (NESARC Study) Mood Disorders Co-Occurring Disorders

8. Denial, Stigma and Access to Care

9. Only an estimated 1.1 million adults received treatment for illicit drug use disorders and 1.5 million adults received treatment for alcohol use disorders in 2005 5.2 million adults needed treatment for illicit drug use disorders but did not receive it 16.4 million adults needed treatment for alcohol use disorders but did not receive it

10. Only an estimated 142,000 adolescents received treatment for illicit drug use disorders and 119,000 received treatment for alcohol use disorders in 2005 1.1 million adolescents needed treatment for illicit drug use disorders but did not receive it 1.3 million adolescents needed treatment for alcohol use disorders but did not receive it

11. Treatment and Recovery

12. Person’s Entry into treatment Discharge Substance use disorders are too often viewed by the funder and/or service provider Severe Remission Tom Kirk, Ph.D

13. Current Service Response Severe Remission Acute symptoms Discontinuous treatment Crisis management Tom Kirk, Ph.D

14. Tom Kirk, Ph.D “addicts” “a chronic, relapsing disease” What message are we conveying? Doesn’t anybody ever get better?

15. Continuous treatment response Promote Self-Care, Rehabilitation Recovery-oriented response Severe Remission Tom Kirk, Ph.D

16. Supporting People’s Path to Recovery Severe Symptoms Improved client outcomes Remission Time Tom Kirk, Ph.D

17. Broadening the Continuum of Care • Treatment is part of recovery, which is the larger construct. • Recovery support services are essential to the recovery process.

18. Recovery Support Services • Recovery support services are non-clinical services that assist in removing barriers and providing resources to those contemplating, initiating, and maintaining recovery. • Recovery support services should be made available throughout the continuum of care: • Pre-treatment; • As an alternative to treatment; • During treatment; and • Post-treatment.

19. Assistance in finding housing, educational, employment opportunities Assistance in building constructive family and personal relationships Life skills training Health and wellness activities Assistance managing systems (e.g., health care, criminal justice, child welfare) Alcohol- and drug-free social/recreational activities Culturally-specific and/or faith-based support Examples of Recovery Support Services

20. Social Support and Recovery Support Services • Social support appears to be one of the potent factors that can move people along the change continuum (Hanna, 2002; Prochaska et al, 1995) • Social support has been correlated with numerous positive health outcomes, including reductions in drug and alcohol use (Cobb, 1976; Salser, 1998). • Four types of social support (emotional, informational, instrumental, affiliational) have been identified.

21. Emotional Support Demonstrations of empathy, care, concern • Mentoring, coaching, and support groups

22. Informational Support Assistance with knowledge, information, and skills • Life skills training, job skills training, citizenship restoration, educational assistance, and health/wellness information

23. Instrumental Support Concrete assistance in helping others get things done • Transportation to support groups, child-care, clothing, job application assistance, etc.

24. Affiliational Support Feeling connected to others, having a social group and/or community, developing a pro-social identity in relation to a recovery community • Alcohol- and drug-free social and recreational events; community and cultural events

25. Peer-to-Peer Recovery Support Services • Draws on the power of example • e.g., instillation of hope; universality; social learning • Draws on the desire to “give back” • e.g., altruism; “survivor mission”, “wounded healer” archetype • Are based on notion that both people in a relationship based on mutuality are helped and empowered • e.g., feminist & multicultural theory & practice; servant leadership; 12-step tradition

26. Examples of Peer Recovery Support Services • Peer coaching or mentoring • Peer-led support groups • Assistance in finding housing, educational, employment opportunities • Assistance in building constructive family and personal relationships • Life skills training • Health and wellness activities • Assistance in navigating systems (e.g., health care, criminal justice, child welfare) • Alcohol- and drug-free social/recreational activities

27. RCSP Portfolio • 27 grants providing peer recovery support services • 20 States • Recovery community organizations and facilitating organizations • Diverse populations served

28. Population-Specific Services • Women • Self-defined groups by culture, ethnicity, sexual orientation or religion • Co-occurring disorders • Ex-offenders • Trauma survivors • Families • Age

29. Establishing a Framework for a Recovery-oriented Approach

30. Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence and improved health, wellness, and quality of life.

31. Framework for Change • National Summit principles and systems elements are intended to provide general direction for those operationalizing recovery-oriented systems of care. • Principles and systems elements can inform development of core measures, promising approaches, and evidence-based practices.

32. Research Supporting Recovery Principles and Recovery-oriented Systems of Care (ROSC) • CSAT is developing a “White Paper” on research supporting the National Summit guiding principles of recovery and systems of care elements. • Paper provides evidence that supports and validates services and systems improvements based on recovery-oriented approaches. • White Paper will be a resource for policymakers, providers, practitioners, recovery support staff, and researchers to plan and implement ROSC. • Copies of the Paper will be distributed at regional meetings and via the Partners for Recovery website.

33. Preliminary Assessment of Supporting Research • At this stage in the development of the paper, over 130 articles have been found to support the recovery principles (55 articles) and systems elements (84 articles). • The white paper includes literature utilizing the following types of qualitative and quantitative research designs: • Case Studies, in-depth interviews, focus groups, quasi-experimental studies, and single group pre-post effectiveness studies. • Generally, 1/3 of the principles and systems elements are supported by extensive research; 1/3 are supported by modest research; and 1/3 are associated with minimal research.

34. Extensive research supports the following principles and elements: Principles of Recovery Many pathways to recovery Recovery involves a personal recognition of the need for change and transformation Recovery has cultural dimensions Recovery exists on a continuum of improved health and wellness Recovery is supported by peers and allies Recovery is a reality Preliminary Assessment, cont’d Systems of Care Elements • Person-centered • Individualized and comprehensive services across the lifespan • Ongoing monitoring and outreach

35. A modest foundation of research supports the following principles and elements: Principles of Recovery Recovery is self-directed and empowering Recovery involves addressing discrimination and transcending shame and stigma Recovery involves (re)joining and (re)building a life in the community Preliminary Assessment, cont’d Systems of Care Elements • Family and ally involvement • Systems anchored in the community • Continuity of care • Strength-based • Culturally responsive • Responsiveness to personal belief systems • Integrated services • Commitment to peer recovery support services

36. Minimal research supports the following principles and elements: Principles of Recovery Recovery is holistic Recovery emerges from hope and gratitude Recovery involves a process of healing and self-redefinition Preliminary Assessment, cont’d Systems of Care Elements • Partnership-consultant relationships • Inclusion of the voices and experiences of recovering individuals and their families • System-wide education and training • Adequately and flexibly financed

37. CSAT’s Commitment to Recovery • CSAT is planning to infuse recovery principles into our policies, programs, and products. • We will also inform and support SAMHSA’s larger efforts to promote recovery by offering substance use disorder-related recovery ideas that can be incorporated into the larger behavioral health picture.

38. Access to Recovery • Assures client choice of service providers; • Implements a voucher system for clients seeking substance abuse clinical treatment and/or recovery support services; • Conducts significant outreach to a wide range of service providers that previously have not received Federal funding, including faith-based and community providers • Monitors outcomes, tracks costs, and prevents waste, fraud and abuse

39. ACCESS to RECOVERY Connecticut’s Recovery-oriented Approach

40. Connecticut’s ATR Model • High degree of collaboration with other targeted State agencies • Five regional networks - a total of 36 clinical and 130 recovery providers (including peer and faith-based) to ensure client choice • One lead agency in each network assisting with implementation, certification of providers, auditing, etc.

41. Collaborative Agencies & Programs • Department of Correction • Judicial Branch • Department of Children and Families • Department of Social Services • Primary Healthcare Sites (Hospital ED & FQHC Sites) • DMHAS-funded Outreach & • Engagement Urban Initiatives

42. Clinical Services • Evaluation • Brief Treatment • Ambulatory Detoxification • Intensive Outpatient (IOP) • Methadone Maintenance • Recently implemented: an evidenced based model of IOP for individuals using cocaine and/or methamphetamines

43. Recovery Support Services • Short-term Housing • Case Management • Childcare • Transportation • Vocational/Educational Services • Basic Needs (food, clothing, personal care) • Faith-based Services • Peer-based Services Two thirds of CT’s ATR service budget is invested in Recovery Support Services, not clinical services.

44. More people working and in housing, less inpatient costs % Working or in training DMHAS established new supportive housing units for over 550 people with psychiatric or substance use disorders. Over 60% of these people are now working or in training, and their inpatient costs have decreased 70%. Based on a Corporation for Supportive Housing study, these supportive housing units are projected to generate over $140 million in direct and indirect economic benefits for the state. Inpatient costs

45. Putting People to Work Enhancing Employment and Self-Sufficiency through Vocational Rehabilitation The likelihood that a person served by DMHAS will become gainfully employed is more than doubled when he/she receives vocational rehabilitation. It pays!!

46. Year To DateAugust 3, 2004 – June 11, 2006 • 10,158 Unduplicated Individuals Served • Year 1 Total Unduplicated Individuals: 106 • Year 2 Total Unduplicated Individuals: 10,032 • Received over 75,000 service level authorizations (clinical and/or recovery support services) • $10,228,529 total paid claims

47. FY2007 ATR Funding • Estimated Amount: $96 million • The ATR program builds upon the successful initiative established in FY 2004. • A target of $25 million per year within ATR to address methamphetamine • Eligibility is limited to the immediate office of the Chief Executive (e.g., Governor) in the States, Territories, District of Columbia; or the head of an American Indian/Alaska Native tribe or tribal organization.

48. 2007 ATR Grant • Posted March 23, 2007 • Applications are DUE by June 7, 2007 • Approximately 18 Awards to be funded • Applicants may request up to $7 million in total costs (direct plus indirect). • Grant award range: $1 million to $7 million • Grants will be awarded for up to 3 years

49. Submission of ATR Applications • Download required documents at http://www.samhsa.gov/Grants/2007/TI_07_005.aspx • No hand carried Applications • Applications may be shipped or submitted electronically • DHL, FedEX, UPS or USPS • www.Grants.gov

50. Conclusion • Movement toward recovery-oriented systems of care involves a significant systems-change. • Recovery-oriented systems of care should: • Encourage greater access to services; • Intervene earlier with individuals with substance use problems; • Improve treatment outcomes; and • Sustain long-term recovery for those with substance use disorders.