The New Recovery Paradigm:The Coming ... - William L. White

The New RecoveryParadigm:The ComingTransformation of AddictionTreatment in AmericaWilliam L. WhiteChestnut Health Systems(bwhite@chestnut.org)

Presentation Goals1. Describe the shift in governing models inaddition treatment from pathology andintervention paradigms to a recovery paradigm2. Outline a series of recommendations that willhelp shift addiction treatment from a model ofacute stabilization to a model of sustainedrecovery management, with a particular focuson post-treatment treatment recovery support services

Perspective: Multiple Roles• Personal recovery & recovery advocacy• 36 years in the addictions (early years asa clinician, clinical director & trainer)• Past 20 years in clinical research• Treatment & recovery historian• An epiphany in Dallas, Texas

The Pathology ParadigmFocus: Etiology and course of AOD problemsAssumption: Sources of AOD problems will revealtheir potential solutionContributions of Model: Charting of multiplepathways into AOD problems , new medicationsin treatment of addiction, etc.Limitations: Health defined as absence of illness.

The Intervention ParadigmAssumptions: Using and evaluating multipletreatment interventions will eventually reveal themost successful solutions to AOD problemsContributions: hundreds of thousands of people inrecovery through Tx pathwayLimitations: Focus on short term stabilizationrather than long-term recovery

The Recovery ParadigmSolutions to AOD problems already exist inlives of millions of individual/families.Improved strategies can come from theexperience, strength & hope of thosealready in recovery.Confluence of Recovery as an OrganizingConcept in Addictions and Mental HealthFields

New Recovery AdvocacyMovementOrganization (NCADD, FaVoR, , JI, LAC, grassrootsrecovery advocacy organizations)Action Agendas• Transform public opinion & public policy• Pursue recovery research• Enrich recovery resources• Transform addiction treatment into a recovery-oriented system of care

The Acute Care Model ofAddiction Treatment• Encapsulated set of service activities (assess,admit, treat, discharge /brief continuing care,termination of service relationship).• Professional expert drives the process.• Service episodes transpire over a relatively shortperiod of time (most less than 90 days).• Individual/family is given impression atdischarge (“graduation(graduation”) ) that recovery is nowself-sustainable sustainable without ongoing professionalassistance.

Treatment (Acute Care Model)Works!Post-Txremissions one-third, AOD usedecreases by 87% following Tx, , &substance-related problems decrease by60% following Tx (Miller, et al, 2001).Lives of individuals and families transformedby addiction treatment.

Treatment Works, BUTLOW ATTRACTIONOnly 10% of those needing treatment received itin 2002 (SAMHSA, 2003) & access compromisedby waiting lists (Donovan, et al, 2001).HIGH ATTRITIONMore than half of clients admitted to addictiontreatment do not successfully completetreatment

Treatment Works, BUT…LOW SERVICE DOSEInadequate doses of Tx contribute to risk ofrelapse & future readmissionsLACK OF CONTINUING CAREOnly 1 in 5 adult clients participated incontinuing care (McKay, 2001) and only 36% ofadolescents received any continuing care(Godley, Godley & Dennis, 2001)

Role of Recovery Mutual AidParticipation in peer-based recovery supportgroups (AA/NA, etc.) is associated withimproved recovery outcomes (Humphreyset al, 2004), but is offset by high (35-68%) attrition in participation followingtreatment (Makela(Makela, , et al, 1996; Emrick,1989)

Treatment Works, BUT…POST-TREATMENT TREATMENT RELAPSEThe majority of people completing addictiontreatment resume AOD use in the year followingtreatment (Wilbourne(& Miller, 2002).Of those who consume alcohol and other drugsfollowing discharge from addiction treatment,80% do so within 90 days of discharge(Hubbard, Flynn, Craddock, & Fletcher, 2001).

Acute Care Treatment as aRevolving DoorOf those admitted to the U.S. publictreatment 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 thefifth or more time (OAS/SAMHSA, 2005).

Recovery StabilityDurability of alcoholism recovery (the pointat which risk of future lifetime relapsedrops below 15%) is not reached until 4-54years of remission (Jin, et al, 1998).20-25% 25% of narcotic addicts who achieve fiveor more years of abstinence later return toopiate use (Simpson & Marsh, 1986; Hser,et al, 2001).

Fragility of Early RecoveryMost individuals leaving addiction treatment arefragilely balanced between recovery and re-addiction in the hours, days, weeks, months,and years following discharge.Recovery and re-addiction decisions are beingmade at a time that service professionals havedisengaged from their lives, while many sourcesof recovery sabotage are present.

Scott, Foss & Dennis Chicago Study (2005)Recovery & Relapse Cycling over 3 yearsSample: 1,326 adults treated in Chicago TxfacilitiesMeasurement: Interviews at 6 months; 24months; 36 months following index TxStatus: in community using, incarcerated, intreatment, or in community not usingFinding: 83% changed status at least once during3 years; 36% 2 times; 14% 3 timesScott, Foss, & Dennis (2005)

Recovery PrevalenceStudies of people meeting lifetime criteria for aDSM-IV Substance Use Disorder in communityand treatment samples reveal that 58-60%eventually achieve sustained recovery (i.e., nodependence or abuse symptoms for the pastyear) (Kessler, 1994; Dawson, 1996; Robins &Regier, , 1991; Dennis et al, 2005).Questions: How do we convey the reality ofrecovery? How do we increase theprevalence of recovery?

Addiction/Treatment/RecoveryCareersStable substance dependence recovery among Txpopulations usually follows multiple Tx episodesover years (Anglin(Anglin, , et al, 1997; Dennis, Scott, &Hristova, , 2002).Question: How do we shorten addictioncareers and extend the length and qualityof recovery careers.

Calls for a New Model ofTreatment: Many Names• Chronic Disease Management (O=Brien(&McLellan, , 1996; McLellan, , et al, 2000)• Extending Case Monitoring (Stout, et al, 1999)• Recovery Management (White, Boyle & Loveland1998, 2002; Dennis, Scott & Funk, 2003)• Assertive Continuing Care (Godley, Godley &Dennis, 2001)

Emerging (rediscovered)Strategies to Enhance RecoveryOutcomes1. Post-treatment treatment monitoring2. Sustained recovery coaching3. Stage-appropriate appropriate recovery education4. Assertive linkage to communities ofrecovery5. When needed, early re-intervention6. Recovery community resourcedevelopment

Dennis, Scott & Funk ChicagoAdult Study (2003)Effect of Recovery Management Checkupson CycleSample: 448 individuals randomlyassigned to receive over 2 yrs eitherquarterly assessment interviews orquarterly recovery management(assessment with re-intervention andlinkage to Tx)

Recovery Management CheckupsStudy FindingsThose assigned to RMC more likely to returnto Tx sooner, spend more days in Tx, , &less likely to be in need of Tx at 24months

Godley, Godley, Dennis, et al,Adolescent Study (2002)Sample: 114 adolescents discharged fromIP Tx randomly assigned to aftercare asusual or assertive continuing care (ACC)ACC Intervention: Home visits, sessions foradolescents, parents and joint sessions,case management

Effects of Assertive Continuing CareFindings at 3 months1. ACC group had a significantly higherengagement/retention rate2. ACC group averaged more than twice thecontinuing care sessions as the control group3. ACC group showed lower relapse rates foralcohol and cannabis; days to first use longerin ACC group members who did use

Other Studies are Confirmingthe Clinical and CostEffectiveness of:• Telephone-based post-treatmenttreatmentmonitoring and support (McKay, 2005)• Internet-based recovery support services(Virtual Recovery) (White & Nicolaus,2005)• Recovery Homes and Voluntary RecoveryCommunities (Jason, et al, in press)

Future of Post-TreatmentMonitoring and Support10 Recommendations

1. Tell the Truth about TreatmentOutcomesChallenge the expectation that full recovery shouldbe achieved from a single Tx episode. Educatestaff, clients, families, employers and alliedprofessionals on the need for sustained recoverymanagement similar to that applied to themanagement of such illnesses as diabetes andheart disease.

2. Change our attitudes towardindividuals with prior treatmentPrior Tx is not an indicator of poor prognosisand should not be grounds for serviceexclusion. Confront any perception ofreturning clients as “losers” who are takingup space that others deserve. We need towelcome returning clients, praise them forservice re-initiation, offer immediate support,and help them extract lessons from theirrelapse experiences.

Rethinking RecidivismBill Wilson (Co-founder of AA) & Marty Mann(Alcoholism Public Health pioneer) had 10 priorTx episodes between them before the Txs thatled to their permanent recoveries and theirhistorical contributions.How might history have been different if they hadbeen treated as “losers” or “retreads”and denied access to treatment?

3. Stop Providing SerialEpisodes of the Same TxRe-examine examine the practice of repeatedly providingthe same treatment services that have failed togenerate sustained recovery.All Tx methods have optimal responders, partialresponders, & non-responders. We must searchfor potent combinations and sequences of Txand recovery support services by giving staffpermission to rethink assumptions/methods andcombine service/support elements in new ways.

4. Promote a Philosophy ofChoiceAcknowledge the legitimacy of multiplepathways and styles of recovery andpromote a philosophy of choice in post-treatment recovery support resources.We must all become experts on the varietiesof recovery pathways/experiences. Wehave been trained as addiction experts; itis time we became recovery experts!

5. Integrate Multiple TxEpisodes within a Long-termRecovery PlanLink episodes of past and future treatment byconceptualizing the overall course ofrecovery management. Shift the serviceemphasis from detoxification andstabilization (early recovery initiation) tolong-term recovery consolidation andmaintenance. Conceptualize and implementmulti-year service plans for clients with highproblem severity/complexity and lowrecovery capital.

6. Replace “Aftercare as anAfterthought” with Sustainedand Assertive Continuing Care• Abandon use of the term “aftercare”;; ongoingrecovery management is the essence of Tx, , notan optional adjunct.• Abandon “discharge planning” and providesustained continuing care as an expectedcomponent of treatment for individuals with highproblem severity & complexity.• Design and implement systems of assertivecontinuing care

Assertive Continuing Carevs. Traditional Aftercare1. Provided to all Clients not Just ThoseWho “Graduate”2. Responsibility for Contact: Shifts fromClient to the TreatmentOrganization/Professional (like mydentist office)

Assertive Continuing Carevs. Traditional Aftercare3. Timing: Capitalizes on Critical Windowsof Vulnerability (first 30-90 days followingprimary Tx) ) and Power of SustainedMonitoring (Recovery Checkups)4. Intensity: Ability to IndividualizeFrequency and Intensity of Contact basedon Clinical Data

Assertive Continuing Carevs. Traditional Aftercare5. Duration: Continuity of Contact over Time witha Primary Recovery Support Specialist (Recoverycheckups over 2-525 years or longer)6. Location: Community-based versus Clinic-based(Focus on the ecology of recovery)(Integration of clinical and communitydevelopment models)7. Staffing: May be Provided in a Professional orPeer-based Delivery Format

7. Shift Service Relationships fromBrief Expert Model to SustainedPartnership/Consultation ModelPromote service relationships that areless ess hierarchical (partnership model) andless transient. Promote a sustainedrecovery support relationship that isanalogous to service relationships crucialto the long-term management ofdiabetes, hypertension, asthma and otherchronic primary health conditions.

8. Explore Creative Strategies forTelephone- & Internet-basedRecovery Support ServicesUses of Telephone & Internet-based Systems ofACCCurrent Models: Betty Ford Center, Hazelden1. Maintaining the recoveryrelationship/partnership (Scott’s s concept pf“creating valued space” in the client’s s life)2. Monitoring & feedback3. Recovery coaching4. Early Re-intervention4.

9. Facilitate Client Involvementin Voluntary Communities ofRecovery• More effective use of sober housing• Nurture the development and diversity of peer-based recovery support groups & permanentrecovery communities• Strengthen relationships with local recoverysupport groups• Rebuild volunteer and alumni programs• Develop protocol for assertive linkage (e.g.,matching to groups, meetings, individuals)

10. Design & Implement Peer-based Recovery Support ModelsIncreased use of Recovery Coaches (alsocalled recovery assistants, recoverysupport specialists, peer mentors)Future• Pre-TxRecovery Priming• In-TxRecovery Support Services• Post-TxRecovery Support Services

Recovery: A Conceptual &Human Bridge• Historical Conflict between addictions andmental health fields• Battles over problem ownership, theories ofcausation & treatment methods.• Trapped in our own historical modelsAddictions—Pathology focus, time-limited serviceMental Health—Pathology focus, time-sustainedserviceBoth have lacked a fully developed, vibrantrecovery concept as their organizing center

Recovery: A Conceptual &Human Bridge• Recovery as an emerging organizing concept hasenormous potential for person-centered modelsof service integration.• Recovery advocates from these two fields aremeeting with increased frequency and findingcommon ground. They will exert a significantinfluence on service systems in the comingdecade.

Recovery: A Conceptual &Human Bridge• The voices of advocates from both fieldsare clear: Recovery is more than theabsence of disease. It is about ameaningful & purposeful life, autonomy &choice, safety & security, friendship &love, family participation, productivity &play and it is about citizenship and serviceto others.

New Guiding VisionsRecovery by Any MeansNecessary!Continuity of Contact in aSustained RecoverySupport Relationship

Primary Resources• www.bhrm.org• White/Boyle/Loveland (2003) AlcoholismTreatment Quarterly, , 3/4:107-130;130; BehavioralHealth Management 23(3):38-44.• White, W. (2005). Recovery Management:What if we really believed addiction was achronic disorder? GLATTC Bulletin.September, pp. 1-7. 1• White, W. & Kurtz, E. (in press) The Varietiesof Recovery Experience GLATTC Monograph