Alexandre B. Laudet, Ph.D Institute for Research, Education, and Training in Addictions

1. ADDICTION RECOVERYWhere 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

2. All ears…

3. ACT ONEWHY ARE WE HERE TODAY?

4. 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? • Acutemodel 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

5. 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)

6. 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

7. 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 globalhealth, wellness, and recovery

8. Recovery Oriented System of Care • THIS SOUNDS VERY GOOD • THIS MEANS BIG CHANGES (more PAPERWORK???) • HOW DO WE GET THERE? • NEED TO KNOW • What recovery means • What helps/hinders the process • How this can be translated into services and policy • At the patient level • At the program level • At the system level

9. 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

10. How can we promote/support an outcome we have not examined and poorly understand?

11. We need a science of recovery to inform Recovery Oriented Systems of Care

12. Whatwill the science of recovery do? Support the development, monitoring and evaluation of ROSC at all 3 levels by answering: • Destination: Where are we going? Specifically what are we trying to promote (what is recovery? long-term recovery)? • Roadmap: How do we get there?What to put in our recovery-oriented services toolbox to best serve clients as their needs change? • Are we there yet? How can we measure recovery outcomes? (for service monitoring and quality improvement, accountability)

13. Summary of key datasetsused in today’s presentation NIDA funded studies conducted in NYC 2002 - 2009

14. 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-, two- and 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

15. Pathways participants were classified by baseline abstinence duration according to clinically meaningful stages

16. 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

17. ACT TWOWHERE DO WE NEED TO GO?Recovery

18. Substance users try to quit becausethey 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) Laudet & White, 2004a

19. Does quitting use ‘lead’ to a better life???

20. Benefits of recovery:Open-endedaWhat, if anything, is/would be good about being in recovery?RECOVERY = A BETTER LIFE a Add to > 100% because up to 3 answers were coded

21. Stress and Quality of Life Satisfaction as a Function of abstinence duration (N = 354) Laudet, Morgen & White, Alc. Tx Q. 2006

22. Recovery definitions

23. 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)

24. Let’s ask the REAL experts… People in recovery! Let’s ask the REAL experts…people in recovery!

25. Recovery definition: Open-endedaHow would you define "recovery from drug and alcohol use"?RECOVERY GOES BEYOND SUBSTANCE USE a Add to > 100% because up to 3 answers were coded; Laudet, JSAT, 2007

26. 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

27. Recovery is a process, not an endpoint “Recovery isa continuous processthat never ends” Laudet, JSAT, 2007

28. Relevance to ROSC Recovery is a realityRecovery is a Process of Change and Growth Recovery is Sobriety + improved quality of life

29. Destination Recovery: Few Direct flights

30. FOR TOO MANY PEOPLE, ADDICTIONISA CHRONIC RELAPSING CONDITION…That’s where ROSC comes in…

31. Addiction careerNumber of abstinent periodsone 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 *Outside of controlled environment, among those who report one or more such periods:71% N=248 Laudet & White 2004b

32. Relevance to ROSC Continuity of services and supports

33. ACT THREEWhat’s wrong with the current model?

34. NYC Outpatient treatment outcome Completion rate on par w/ national average of 36% for outpatient modalities Laudet, Stanick, & Sands, JSAT 2009

35. % 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) Chi. Sq. 35.5, p = .0000 Stanick, Laudet & Sands, 2008

36. Treatment Career: Number of prior episodes Over half of outpatient clients have had 3 or more previous episodes Laudet, Stanick & Sands, Eval Review, 2007

37. One third seek treatment again in the 12 months after leaving the index episode Laudet and Stanick, CPDD 2010

38. Reasons for leaving treatment: Qualitative analyses What is the most important reason why you dropped out of the program?* * Add to > 100% because up to 2 answers were coded;Laudet, Stanick, & Sands, JSAT 2009, 37:182-190

39. Minimizing attrition [1] Is there anything the program could have done differently so that you would have continued attending? Laudet, Stanick, & Sands, JSAT 2009

40. Minimizing attrition [2] What could have been done differently so that you would have continued attending (among ‘yes’) Laudet, Stanick, & Sands, JSAT 2009

41. Substance use is but a symptom, Promoting abstinence is not enough

42. Expectation of helpOverall, how much do you think your coming to this treatment program will help you address your needs and priorities?

43. 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’) Laudet, Stanick, & Sands, JSAT 2009

44. Quality of life satisfaction sustains abstinence…

45. Quality of life satisfaction predicts sustained abstinence: Community based sample Want that feeling Pass on Donut DIET Jeans fit better SAY NO TO DRUGS Want to stay happy HAPPIER Stop 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

46. “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 participantBehavioral economics: Demand law

47. But what makes them happy???

48. Priorities @ outpatient admissionWhat are the priorities in your life right now? (N = 314) Abstinence is top goal but not only goal!!!

49. Life priorities in recovery by abstinence duration “What are the priorities your life right now?”(N = 354) Laudet & White, JSAT 2009

50. Relevance to ROSC Individualized and comprehensive services/supports Multi-system Integrated services