The Science of Sober Living: Housing Policy and Community Resilience to Addiction Kevin T. McCauley, MD Utah Fall Conference September 2014

I. Background

Neuroscience of addiction and how it applies to Sober Living

ASAM Addiction Definition (Aug 2011)

A stress-induced (HPA axis), genetically-mediated (polymorphisms, epigenetic mechs.) primary, chronic and relapsing brain disease of reward (nucleus accumbens), memory (hippocampus & amygdala), motivation and related circuitry (ACC, basal forebrain) that alters motivational hierarchies such that addictive

behaviors supplant healthy, self-care behaviors

Relapse Three things that are known to evoke relapse in humans: 1. Brief exposure to drug itself (DA release in NAc) drug-induced reinstatement 2. Exposure to drug cues (GLU release in blAmyg/Hipp) cue-induced reinstatement 3. Stress (CRF release in CeAmyg & BNST) stress-induced reinstatement (example of a dangerous relapse-triggering behavior: talking about drugs (cues) with other newly-sober addicts in

treatment (stressed) while smoking (DA surge)

Social Defeat Stress • Dominant and Submissive monkeys (ie. monkeys

exposed to social defeat) have differences in DAD2 receptors

• If offered cocaine, dominant monkeys are less likely to acquire regular self-administration

• But submissive monkeys acquire cocaine self-administration rapidly …

• … and cocaine reinstatement occurs quickly in submissive monkeys if exposed to social defeat stress (they relapse immediately - even in the absence of physical stress)

• SDS is an example of “loss of agency” dys-stress • Question: Is socially dominating “treatment” inviting

relapse?

Strategies to deal with the STRESS component of addiction

• Safe housing • Recognize unconscious aspects of relapse • Ritualistic, daily (hourly) stress

management activities • Supportive peers • Medication (alpha- and beta-blockade) • Minimize social dominance

ACUTE Disease vs CHRONIC Disease

• REDUCTIVE: simple causation (traumatic, infectious, toxicologic)

• EMERGENT: rapid onset, severe symptoms, short duration

• EPISODIC CARE: Usually cured with a single, intense, time-limited hospitalization involving definitive treatment with …

• MATERIALISTIC: primarily surgical or pharmacological interventions

• TECHONOCRATIC: Expert delivered, expensive, encourages “sick role” dependency, poorly targeted, fragmented care

• Ex. Heart Attack, Pneumonia, Encephalitis, traumatic injury

• CONTEXTUAL: multiple causation (genetic vulnerability, early adverse experiences, poverty, societal disenfranchisement

• VARIABLE COURSE: sudden or gradual onset, relapsing, life-course variations

• LONGITUDINAL CARE: non-urgent, across the life-span, electronic health records, preventive focus

• PATIENT-CENTERED: care takes personal values, cultural context and spiritual considerations into account

• COMMUNITY-BASED: mix of professional and lay-treatment, team approach, continuous relationships

• Ex. Heart Disease, Diabetes, Asthma, Addiction, Depression, etc.

Recovery Management

Recovery management is a philosophy of organizing addiction treatment and recovery support services to enhance pre-recovery engagement, recovery initiation, long-term recovery maintenance, and the quality of personal/family life in long-term recovery. Goal: improving quality of life and reducing healthcare costs for individuals with addiction by preventing or minimizing the effects of the disease through integrative care

Recovery Capital (Granfield & Cloud)

Recovery Capital is the sum total of all the personal, social, and community resources a person can draw on to begin and sustain their recovery from drug and alcohol problems.

Recovery-Oriented Systems of Care (ROSCs) support person-centered and self-directed approaches to care that build on the strengths and resilience of individuals, families, and communities to take responsibility for their sustained health, wellness and recovery from drug and alcohol problems.

Recovery-Oriented Systems of Care (ROSCs)

White House’s “Third Way” Policy

Saitz: AHEAD Study - JAMA 2013, 310(11)

• No significant difference in abstinence from opiods, stimulants or heavy drinking between the CCM group and control group.

“Although CCM is designed to address complex problems, it may simply not be enough to overcome the impaired motivation and myriad severe consequences experienced by patients with addictions. “

II. A Primer on Housing Law

… as it applied to Sober Living

Civil Rights Act (1964)

Fair Housing Act of 1968 (FHA) (42 U.S.C. §§ 3601-3631) [ aka Title VIII of the Civil Rights Act (1968) ]

• Passed by Congress and signed by President Lyndon Johnson one week after the assassination of Martin Luther King, Jr

• Regulates housing-related transactions including advertising, mortgage-lending, homeowner’s insurance and zoning

• Designed to protect against/outlaw discrimination and “restrictive covenants” (to refuse to sell to/rent to/negotiate with a person in a protected class)

• Outlawed “blockbusting” – the practice of frightening homeowners by telling them that people in a protected class are moving in and property values will decline as a result

• Judges can award actual damages, equitable relief, and attorney’s fees to the prevailing party (but not punitive damages)

Rehabilitation Act of 1973 (29 U.S.C. § 701 )

• Signed by Richard Nixon • Prohibits employment discrimination and

requires affirmative action by Federal Agencies and contractors

• Established the EEOC

Fair Housing Act Amendments of 1988 (FHAAA) (42 U.S.C. §§ 3601-3631)

• Strengthened the FHA by making it unlawful for local governments to discriminate in the sale or rental, or to otherwise make unavailable or deny, a dwelling to any buyer or renter because of a handicap

• The Act defined “handicap” extremely broadly as (1) a physical or mental impairment which substantially limits one or

more of [a] person's major life activities, (2) a record of having such an impairment, or

(3) being regarded as having such an impairment. • Exceptions to this definition, including those "whose tenancy would

constitute a direct threat to the health or safety of other individuals or whose tenancy would result in substantial physical damage to the property of others” and people afflicted with the "current, illegal use of or addiction to a controlled substance”

Foote JH. The Fair Housing Act Amendments Act of 1988 and Group Homes for the Handicapped. Hazel & Thomas, P.C.,

Manassas, Virginia Reprinted from the Journal of the Section on Local Government Law of the Virginia State Bar, Vol. III, No, 1, September 1997

Americans with Disabilities Act (42 U.S.C. §§ 12111-12213)

• Signed in 1990 by President George H.W. Bush (amended by the ADAAA by President George W. Bush in 2008)

• Wide-ranging civil rights law designed to afford similar protections as the CRA (1964) to persons with disabilities

• Prohibits discrimination based on disability in employment, public transportation, public accommodations and telecommunications

• Reasonable Accommodation: necessary and appropriate modification not imposing a disproportionate or undue burden, where needed in a particular case, to ensure to persons with disabilities the enjoyment or exercise on an equal basis with others of all human rights and fundamental freedoms

• Title V: anti-retaliation and coercion provision

SAMHSA TAP 14: Siting Drug and Alcohol Treatment Programs - Legal Challenges to the NIMBY Syndrome

“This manual examines the legal remedies available to alcohol and drug treatment providers who wish to challenge discriminatory zoning and siting decisions that result from the NIMBY syndrome”

http://www.lac.org/doc_library/lac

/publications/siting.pdf

Zoning / Coding • Local laws that regulate how a landowner may use his/her property

(aka land use restrictions) • Zoning ordinances: impose requirements on the way a building is

constructed or situated • Enabling Statutes: authority to make zoning decisions conferred on

local governments • Enactment and enforcement must have a rational basis • “Police Power” – gives local governments the right to make

decisions that advance and protect the health, morals, safety and general welfare of the community

• Ex. Govt can prevent the construction of a hospital in a flood plain • Cannot be arbitrary, unreasonable, or capricious

Siting Drug and Alcohol Treatment Programs: Challenges to the NIMBY syndrome. US Dept of Health and Human Services, Substance Abuse

and Mental Health Services Administration, July 1995.

Zoning A community cannot use its zoning ordinances to

discriminate against classes of people that it does not want to accept, such as alcohol and drug dependent persons. Courts have consistently ruled that if an ordinance is intended to exclude certain groups from the community, or in some cases, if an otherwise "neutral" ordinance has a discriminatory effect, then the zoning decision may be voided on the grounds that it violates anti-discrimination statutes or rights and protections guaranteed by the United States Constitution.

Siting Drug and Alcohol Treatment Programs: Challenges to the NIMBY syndrome. US Dept of Health and Human Services,

Substance Abuse and Mental Health Services Administration, July 1995.

Special Use Permit • Enables development in zones not normally eligible for

siting • Allow a community flexibility in zoning while maintaining

regulatory control • Local board will look at compatibility with neighborhood,

effect on property values, impact on public health, morals, safety and general welfare

• Have detailed info ready, be prepared for community opposition

• Usually requires a public hearing

Variance • AREA VARIANCE: eases the layout or structural

requirements that make building on a piece of property difficult

• USE VARIANCE: allow exceptions to the land use restrictions contained in a zoning ordinance

• Usually granted when enforcement of the zoning ordinance would result in an “unnecessary hardship” for the property owner (ie. strict adherence to the limitations imposed by the zoning ordinance would likely deny the landowner a reasonable return on the value of his or her property)

Special Use Permits In Bangerter v. Orem City, Utah, 46 F.3d 1491 (10th Cir.

1995), for example, the court of appeals found that requirements that a group home for mentally retarded adults give assurances its residents would be properly supervised on a 24-hour-a-day basis, and that the home establish a community advisory committee to deal with neighbor's complaint, were not imposed on other communal living arrangements under the City's zoning ordinance, and were intentionally discriminatory.

Siting Drug and Alcohol Treatment Programs: Challenges to the NIMBY syndrome. US Dept of Health and Human Services,

Substance Abuse and Mental Health Services Administration, July 1995.

Fair Housing Act Amendments of 1988 (FHAAA) (42 U.S.C. §§ 3601-3631)

• The House Judiciary Committee said that: The FHAA, as amended, is a clear pronouncement of a

national commitment to end the unnecessary exclusion of persons with handicaps from the American mainstream. It repudiates the use of stereotypes and ignorance, and mandates that persons with handicaps be considered as individuals. Generalized perceptions about disabilities and unfounded speculations about threats to safety are specifically rejected as grounds to justify exclusion. . . .

Foote JH. The Fair Housing Act Amendments Act of 1988 and Group Homes for the Handicapped. Hazel & Thomas, P.C.,

Manassas, Virginia Reprinted from the Journal of the Section on Local Government Law of the Virginia State Bar, Vol. III, No, 1, September 1997

Fair Housing Act Amendments of 1988 (FHAAA) (42 U.S.C. §§ 3601-3631)

While state and local governments have authority to protect safety and health … that authority has sometimes been used to restrict the ability of individuals with handicaps to live in communities. This has been accomplished by such means as the enactment of or imposition of health, safety or land-use requirements on congregate living arrangements among non-related persons with disabilities. Since these requirements are not imposed on families and groups of similar size of other unrelated people, these requirements have the effect of discrimination against persons with disabilities. The Committee intends that the prohibition against discrimination against those with handicaps apply to zoning decision and practices. The Act is intended to prohibit the application of special requirements through land-use regulation, restrictive covenants, and conditional or special use permits that have the effect of limiting the ability of such individual to live in the residence of their choice in the community.

Family Composition Rules

City of Edmonds v. Oxford House, Inc., 514 U.S. 725 (1995) the Supreme Court held that such rules are plainly subject to the FHAA and while limitations on unrelated residents is not per se invalid, they must be scrutinized carefully for their discriminatory intent or effect.

Dispersal Requirements In Larkin v. State of Michigan, 883 F. Supp. 172, 177 (E.D. Mich. 1994)

a state statutory scheme precluded issuance of a license if it would "substantially contribute to an excessive concentration" of such facilities, and required notification be given to the City Council to review the number of existing and proposed facilities within 1500 feet of a proposed facility and to its neighbors. The City argued that its dispersal requirement prevented formation of "ghettos" and normalized the environment. The Court found no rational legal basis for these provisions, and held that they were facially discriminatory, since "the absence of a malevolent motive does not convert a facially discriminatory policy into a neutral policy with a discriminatory effect."

Other Legal and Procedural Obstacles

• Health and Safety Codes • Fire Codes and Clearances • Environmental Quality/Impact Reports • Public Hearings • Licensure

III. How to design a good “sober living” home

What are “best practices?”

What is “recovery”? Betty Ford Consensus Panel (2007) Recovery is a voluntarily maintained lifestyle characterized by: 1. Sobriety: abstinence from alcohol and non-prescribed drugs 2. Personal Health: improved quality of life for the individual

(and their family) composed of defined and measurable physical, psychological, social, and spiritual components

3. Citizenship: living with regard and respect for those around you; working towards the betterment of one’s community through participation, volunteer word, and efforts to improve life for all citizens (“giving back”)

What is “sober living”?

• Myriad of names: halfway house, three-quarter house, sober living, extended care, dry house

• Most of these lack clarity and have a variable meaning depending on mission, clientele, regional differences in policies, licensing and funding

• Creates confusion in trying to match appropriate living environment to individual client needs

“Recovery Residence”

A broad term describing a safe, sober, healthy living environment that promotes individual

recovery from alcohol and other drugs as well as associated problems.

At a minimum, recovery residences provide peer recovery support and facilitate abstinence-

based, long-term recovery. Recovery residences have published policies on

relapse sanctions and re-admission criteria.

The mission of the National Association of Recovery Residences (NARR) is to create, evaluate and improve standards and

measures of quality for all levels of recovery residences. NARR provides a forum for exchanging ideas to include developing uniformity of nomenclature for our field, problem solving and advocacy. We assist existing regional associations in their growth, and foster the development of recovery residence

associations where none exist. NARR is the national resource for recovery residence providers seeking standards, protocols for

ethical practice, training, and state of the art information pertaining to all levels of residential recovery operations.

NARR Levels of Recovery Residence

• Level One – Peer Run Homes • Level Two – Monitored Homes • Level Three - Supervised • Level Four – Service Provider

NARR Standards - Level One (Peer Run)

• Administration democratically run written policies & procedures manual • Services drug screening, house meetings, self-help

meetings • Residence single family residence • Staff overseeing officer, no paid positions

NARR Standards - Level Two (Monitored)

• Administration house manager or senior resident written policies & procedures manual • Services house rules provide structure drug screening, house meetings, self-help meetings • Residence single family residence, apartments • Staff at least one compensated position

NARR Standards - Level Three (Supervised)

• Administration organizational hierarchy, administrative oversight written policies & procedures manual STATE LICENSED • Services drug screening, house meetings, self-help meetings life skills development emphasis clinical services utilized in outside community • Residence varies – all types of residential settings • Staff facility manager certified staff or case managers

NARR Standards - Level Four (Service Provider)

• Administration overseen organizational hierarchy clinical and administrative supervision written policies & procedures manual STATE LICENSED • Services clinical services and programming are provided in the house life skills development • Residence varies – all types of residences (usually a step down phase

within the care continuum of a treatment center) • Staff credentialed staff

IV. One example of a Recovery Residence structure

… based on past successes with impaired professional monitoring

Population served • Time Period: 2 years • Number of Residents: 39 men • Range of Duration of Stay: 14 to 267 days • Average Length of Stay: 98.0 days • Age distribution: x = 28.9, bimodal • 34.4% stayed longer than originally intended • 40.6% stayed shorter than originally intended • 23% re-admission rate (half for relapse, half for

relapse prevention)

Performance data: • Total Delivery: 3619 resident-days • Days Positive Test: 81 days (2.3%) • Days Intoxicated: 83 (2.3%) • Relapsed post-Tx: 48.7% • Readmit Rate: 23% • In contact/Doing well: 46.9% • In contact/improved: 25.0% • In contact/not improved: 23%

Population served • Time Period: 4 years • Number of Residents: 91 men • Range of Duration of Stay: 14 to 267 days • Average Length of Stay: 95.0 days • Age distribution: x = 29.0 years • 30% stayed longer than originally intended • 45% stayed shorter than originally intended • 19% re-admission rate (half for relapse, half for

relapse prevention)

Performance data: • Total Delivery: 7,619 resident-days • Days Positive Test: 137 days (1.8%) • Days Intoxicated: 149 (2.0%) • Relapsed post-Tx: 49% • Readmit Rate: 19% • In contact/Doing well: 35% • In contact/improved: 30% • In contact/not improved: 31%

Kevin McCauley, MD Director of Program Services New Roads Treatment Programs

Sandy, Utah (435) 659-6293

kevin@newroadstreatment.com