Alexandre B. Laudet, Ph.DAlexandre B. Laudet, Ph.DInstitute for Research, Education, and Training in AddictionsInstitute for Research, Education, and Training in Addictions

Tampa, FL ● August 2-4, 2010

ADDICTION RECOVERYADDICTION RECOVERY

Where are we going? How do we get there? Where are we going? How do we get there?

Lessons from the recovery experience for service developmentLessons from the recovery experience for service development

All ears…

ACT ONEACT ONEWHY ARE WE HERE TODAY?WHY ARE WE HERE TODAY?

Why are we here Why are we here today?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?

Acute model 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

A wind of change…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)Recovery Oriented System of Care (ROSC)

Elements of Recovery-Elements of Recovery-Oriented Systems of CareOriented 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-centeredFamily and other ally involvementIndividualized and comprehensive servicesSystems anchored in the communityContinuity of carePartnershipsStrength-basedCulturally responsiveResponsive to personal belief systemsCommitment to peer servicesInclude recovering people and familiesIntegrated servicesSystem-wide educational and trainingOngoing monitoring and outreachOutcomes-driven Evidence-basedAdequately and flexibly funded

From W. Clark, CSAT, Generic ROSC talk

Paradigmatic shifts needed to Paradigmatic shifts needed to implement ROSCimplement ROSC

From intense episodes of acute specialty care to multi-systems, person-centered continuum of multi-systems, person-centered continuum of carecare

From addressing pathology to promoting globalpromoting global health, wellness, and recoveryhealth, wellness, and recovery

Recovery Oriented System Recovery Oriented System of Careof Care

THIS SOUNDS VERY GOOD

THIS MEANS BIG CHANGES (more PAPERWORK???)

HOW DO WE GET THERE?

NEED TO KNOW

1. What recovery means

2. What helps/hinders the process

3. How this can be translated into services and policy

At the patient level

At the program level

At the system level

How much do we know about How much do we know about recoveryrecovery??

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

How can we promote/support an outcome we have How can we promote/support an outcome we have

not examined and poorly understand?not examined and poorly understand?

We need a science of recoveryto inform Recovery Oriented

Systems of Care

WhatWhat will the science of will the science of recovery do?recovery do?

Support the development, monitoring and evaluation of ROSC at all 3 levels by answering:

1. Destination: Where are we going? Specifically what are we trying to promote (what is recovery? long-term recovery)?

2. Roadmap: How do we get there? What to put in our recovery-oriented services toolbox to best serve clients as their needs change?

3. Are we there yet? How can we measure recovery outcomes? (for service monitoring and quality improvement, accountability)

Summary of key datasetsSummary of key datasetsused in today’s used in today’s presentationpresentation

NIDA funded studies conducted in NYC 2002 - 2009

Pathways: Pathways: The community-based The community-based samplesample

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

Pathways participants were classified Pathways participants were classified by baseline abstinence duration by baseline abstinence duration according to clinically meaningful according to clinically meaningful stagesstages

18 to 36 mo.20% 6 to 18 mos.

26%

Three+ yrs27%

< 6 mos. Drug abstinent

27%

Twelve-step as aftercare:Twelve-step as aftercare: The The outpatient treatment sampleoutpatient 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

ACT TWOACT TWOWHERE DO WE NEED TO GO?WHERE DO WE NEED TO GO?

RecoveryRecovery

Substance users try to quit becauseSubstance users try to quit because they want a better lifethey want a better life

83

86

90

92

93

94%

50 75 100

Negative effects of drug use onothers

Weighing pros & cons ofcontinued use

Didn't like what I was becoming

Tired of the drug life

Desire for a better life

Didn't like where life wasgoing/feared consequences

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)(N = 354)

Laudet & White, 2004a

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

Benefits of recovery:Benefits of recovery: Open-endedOpen-endedaa

What, if anything, is/would be good about being in recovery?What, if anything, is/would be good about being in recovery?

RECOVERY = A BETTER LIFERECOVERY = A BETTER LIFE

11

13

16

17

18

16

23

33%

23

0 5 10 15 20 25 30 35

Having friendsBetter family lifeBetter physical/mental health

Better living conditionsBetter attitude

Having direction/goalsSelf-improvement

Clear headNew life/2nd chance

a Add to > 100% because up to 3 answers were coded

Stress and Quality of Life Satisfaction as a Stress and Quality of Life Satisfaction as a Function of abstinence duration Function of abstinence duration (N = 354)

RECOVERY STAGE

3+ years18 to 36 mos

Six to 18 mos>6 months

Mean

(sc

ale ran

ge =

0 to

10)

8.5

8.0

7.5

7.0

6.5

6.0

5.5

5.0

Overall life

satisfaction

Stress rating pst yr

Laudet, Morgen & White, Alc. Tx Q. 2006

Recovery definitionsRecovery definitions

Recovery definitionsRecovery definitions

Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence, improved abstinence, improved health, wellness, and health, wellness, and quality of lifequality of life. (CSAT, 2005 National Recovery Summit)

Recovery from substance dependence is a voluntarily maintained lifestyle characterized by sobriety, personal health, and sobriety, personal health, and citizenshipcitizenship. (Betty Ford Institute, 2007)

Let’s ask the REAL Let’s ask the REAL experts…people in experts…people in

recovery!recovery!

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

Recovery definition: Recovery definition: Open-Open-endedendedaa

How would you define "recovery from drug and alcohol use"?

RECOVERY GOES BEYOND SUBSTANCE USERECOVERY GOES BEYOND SUBSTANCE USE

17%

21%

41%

44%

0 10 20 30 40 50

Dealing w/issues

Lifelong process

Total abstinence

Better life/new life

a Add to > 100% because up to 3 answers were coded; Laudet, JSAT, 2007

My definition of recovery is life… ‘Cause I didn’t have no life before I got into recovery

Laudet, JSAT, 2007

Pathways study participant H.W. 42 years old Af-Am male

Recovery is a Recovery is a processprocess, not an , not an endpointendpoint

“Recovery is a continuous process that never ends”

3.2%

96.8%

0 20 40 60 80 100

Disagree/Stronglydisagree

Agree/Stronglyagree

Laudet, JSAT, 2007

Relevance to ROSC Relevance to ROSC

Recovery is a realityRecovery is a reality

Recovery is a Process of Change and Growth Recovery is a Process of Change and Growth

Recovery is Sobriety + improved quality of Recovery is Sobriety + improved quality of lifelife

Destination Recovery: Destination Recovery: Few Direct flightsFew Direct flights

FOR TOO MANY PEOPLE, FOR TOO MANY PEOPLE, ADDICTIONADDICTION ISIS A CHRONIC A CHRONIC RELAPSING CONDITION…RELAPSING CONDITION…

That’s where ROSC comes That’s where ROSC comes in…in…

Addiction careerAddiction career Number of abstinent Number of abstinent periodsperiods one month or longer followed by return to one month or longer followed by return to drug use prior to current abstinencedrug 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=248Laudet & White 2004b

20 & over10%

Ten to 1917%

Six to nine7%

Four to five16%

Three11%

Two 22%

One17%

Relevance to ROSC Relevance to ROSC

Continuity of services and supportsContinuity of services and supports

ACT THREEACT THREEWhat’s wrong with the current What’s wrong with the current

model?model?

NYC Outpatient treatment NYC Outpatient treatment outcomeoutcome

Completed40%

Left before completion

60%

Laudet, Stanick, & Sands, JSAT 2009

Completion rate on par w/ national average of 36% for outpatient modalities

% Returned to substance use in the % Returned to substance use in the post-treatment year as a function of post-treatment year as a function of discharge statusdischarge status

57.8%

92.6%

0

10

20

30

40

50

60

70

80

90

100

Completed Left beforecompletion Chi. Sq. 35.5, p = .0000

Stanick, Laudet & Sands, 2008

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)

Treatment Career:Treatment Career: Number of Number of prior episodesprior episodes

None21%

One15%

Two12%

Three-four17%

Five to nine21%

Ten +14%

Over half of outpatient clients have had 3 or more previous episodes

Laudet, Stanick & Sands, Eval Review, 2007

One third seek treatment One third seek treatment again in the 12 months after again in the 12 months after leaving the index episodeleaving the index episode

Laudet and Stanick, CPDD 2010

No additional treatment

69%

Additional treatment31%

Reasons for leaving treatment: Reasons for leaving treatment: Qualitative analysesQualitative analyses

What is the most important reason why you dropped out of the program?*

8.5

9.4

12

12

12

12

18.8

31.6%

0 5 10 15 20 25 30 35

Not helpful

Finances

Do not want help

Family/personal issues

Convenience (e.g.,transport)

Using

Tx interferes w/otheractivity (e.g., job)

Dislikeprogram/staff/clients

* Add to > 100% because up to 2 answers were coded; Laudet, Stanick, & Sands, JSAT 2009, 37:182-190

Minimizing attrition [1]Minimizing attrition [1]

Is there anything the program could have done differently so that you would have continued attending?

Yes33%

No67%

Laudet, Stanick, & Sands, JSAT 2009

Minimizing attrition [2]Minimizing attrition [2]

What could have been done differently so that you would have continued attending (among ‘yes’)

Practical assistance

11% Help with other areas of

functioning18%

Better, more caring staff

25%

Better individualized

services23%

Greater flexibility in scheduling

23%

Laudet, Stanick, & Sands, JSAT 2009

Substance use is but a Substance use is but a symptom, Promoting symptom, Promoting

abstinence is not enoughabstinence is not enough

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

Quite a bit24%

Very much71%

Not at all1%

A little4%

Remember this? Remember this? 33% of drop outs may have

stayed longer if they had help in other life areas …Missed Missed opportunities?opportunities?

What could have been done differently so that you would have continued attending (among ‘yes’)

Practical assistance

11% Help with other areas of

functioning18%

Better individualized

services23%

Better/more caring staff

25%

Greater flexibility in scheduling

23%

Laudet, Stanick, & Sands, JSAT 2009

Quality of life Quality of life satisfaction sustains satisfaction sustains

abstinence…abstinence…

Quality of life satisfaction predicts Quality of life satisfaction predicts sustained abstinence: sustained abstinence: Community based sample

Stop drugs

SAY NO TO DRUGS

Want to stay happy

Controlling for other relevant variables, baseline QOL satisfaction predicts sustained abstinence one and two years later.

Association partially mediated by motivation for abstinence

HAPPIER

Laudet, Becker & White, 2009, 44

DIET Jeans fit better Want that feeling

Pass on Donut

“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 participant

Behavioral economics: Demand lawBehavioral economics: Demand law

But what makes them But what makes them happy???happy???

Priorities @ outpatient Priorities @ outpatient admissionadmissionWhat are the priorities in your life right now? (N =

314)

0 10 20 30 40 50

Complete tx

Get life together

Relation w.family

Housing

Get kids back

Educ/Voc/Training

Get a job

Get/Stay clean

Abstinence is top goal Abstinence is top goal but not only goal!!!but not only goal!!!

Life priorities in recoveryLife priorities in recovery by by abstinence duration abstinence duration

“What are the priorities your life right now?”“What are the priorities your life right now?” (N = 354)(N = 354)

0 10 20 30 40 50 60

Housing

Family reunification

Normal life

Educ/ training

Relationships

Employment

Recovery

< 6 mos.

6 - 18 mos.

18 - 36 mos.

> 3 years

Laudet & White, JSAT 2009

Relevance to ROSC Relevance to ROSC

Individualized and comprehensive Individualized and comprehensive services/supports services/supports

Multi-system Integrated servicesMulti-system Integrated services

ACT FOURACT FOURWith a little help from my With a little help from my

friends…friends…

Sources of support in long-term Sources of support in long-term recoveryrecovery PPathways pilot athways pilot (N = 52 CCAR members, median abstinence

duration 12 yrs)

7

11

17

18

43

53

53%

0 10 20 30 40 50 60Clinicians

FriendsSelf/inner strength SpouseRecovering peers FamilySpirituality/faith

Laudet, Savage & Mahmood, J. Psychoactive Drugs, 2002

Lessons learned from RelapseLessons learned from Relapse aa

Top answers (<10%)Top answers (<10%)

a Among those who report one or more such periods: N=253; Laudet & White, 2004b

10.3

11.5

15.1

18.3

18.7

21.8%

I'm an addict/can't use sociallyNeed to address issues/express fe...Cannot recover w/out supportLearn about/avoid from triggersClean =good/drugs = bad

Must want recovery/make it priorit...

What if anything have you learned from the relapse experience?

Strategies to deal with relapse Strategies to deal with relapse triggers:triggers:

Most cited = Seek support, stay focused on Most cited = Seek support, stay focused on recoveryrecovery

Meditate/pray8%

Stay focused42%

Seek help/support, Talk about pb

44%

Distraction6%

C Among those who report a challenge; Laudet & White 2004b

Example of source of support and Example of source of support and motivation: motivation:

Twelve-step fellowshipsTwelve-step fellowships

Role of Role of continuouscontinuous 12-step attendance 12-step attendance on on oddsodds of abstinence sustained for two of abstinence sustained for two years: years: Pathways studyPathways study

6.25

8

5.7

4.54.5

0

4

8

Totalsample

Under 6months

Six to 18months

18 to 36months

Threeyears +

Laudet & White 2006

Relevance to ROSC Relevance to ROSC

Draw on Support from peers, family members, significant

others, friends, and the community

ACT FIVEACT FIVE So what???So what???

Translating Research into Recovery Oriented Systems

Recovery Oriented System of Care Recovery Oriented System of Care makes Sense…makes Sense…

Based on the experience of people in treatment and in recovery, the core elements of ROSC ‘make sense’

The transition to ROSC will

Take time

Take full commitment from the ‘system’ including payors

Take place gradually

Experience and success of ‘leader states/cities’ (e.g., CT, Philly, ) will be invaluable

In the meantime, strive to ADOPT AS MANY ELEMENTS OF ROSC AS BUDGET ALLOWS

Recovery Oriented System of Care Recovery Oriented System of Care makes Cents…makes Cents…

60

Mathematical simulation of the costs of methadone treatment over the lifetime for an opiate dependent individual under the chronic vs. acute model of care: ‘We find that the benefit-cost ratio of treatment from our lifetime model (37.72) exceeds the benefit-cost ratio from a static model (4.86)’ (Zarkin et al., 2005, p. 1133).

NOT CONVINCED YET???

The Connecticut experience* (statewide ROSC)

24% decrease in expenses 46% increase in number of people served statewide62% decrease of acute care40% increase in outpatient care25% decrease in annual cost per client14% lower cost with recovery support

* 2008 statewide data from Kirk, in press in Kelly and White

Let’s get to work!Let’s get to work!

Questions? Comments?Questions? Comments?How can we help?How can we help?

http://www.attcnetwork.org/regcenters/index_northeast.asp www.ireta.org

Email: alexandrelaudet@gmail.com