11
Exploring the recovery process: Exploring the recovery process: Patterns, supports, challenges Patterns, supports, challenges
and future directionsand future directions
Alexandre B. LaudetAlexandre B. LaudetPresented at the Seminar Series of the Division of Epidemiology, Services Presented at the Seminar Series of the Division of Epidemiology, Services
and Prevention Research (DESPR)and Prevention Research (DESPR)
National Institute on Drug Abuse (NIDA)National Institute on Drug Abuse (NIDA)
April 20, 2005April 20, 2005
Center for the Study of Addiction and RecoveryCenter for the Study of Addiction and RecoveryNational Development and Research Institutes, Inc.National Development and Research Institutes, Inc.
Correspondence: Correspondence: [email protected]@ndri.org
In collaboration with…In collaboration with…
Co-Investigators: William L. White, Chestnut//LighthouseCo-Investigators: William L. White, Chestnut//Lighthouse
Gordon Storey, Gordon Storey, Self-Help Addiction Resource Self-Help Addiction Resource Center (SHARC)Center (SHARC)
Statistician: Keith Morgen, NDRIStatistician: Keith Morgen, NDRI
Operations: Virginia Stanick, and Marie Marthol, NDRIOperations: Virginia Stanick, and Marie Marthol, NDRI
Field: Jeffrey Becker, Wanda Bonilla, Nadina Correa, Una Cruz, Field: Jeffrey Becker, Wanda Bonilla, Nadina Correa, Una Cruz, Doug Goldsmith, , Myrta Hernandez, Yolanda Jones, Vanessa Doug Goldsmith, , Myrta Hernandez, Yolanda Jones, Vanessa Rodriguez, Scott Smith, Luis Torres, NDRIRodriguez, Scott Smith, Luis Torres, NDRI
Design: Evette McCoy, NDRIDesign: Evette McCoy, NDRI
BackgroundBackground
This presentation draws on This presentation draws on prospective and retrospective findings from three prospective and retrospective findings from three NIDA-F studies using both quantitative and qualitative methods to explore NIDA-F studies using both quantitative and qualitative methods to explore the recovery experience over time as well as factors that promote and the recovery experience over time as well as factors that promote and hinder the process. hinder the process.
The studies were/are conducted among inner-city participants in New York The studies were/are conducted among inner-city participants in New York City (details in handouts):City (details in handouts):
Pathways to long-term abstinence: Self-help processes, R01DA14409Pathways to long-term abstinence: Self-help processes, R01DA14409
Twelve-step as aftercare: predictors and effectiveness, R01DA015133-Twelve-step as aftercare: predictors and effectiveness, R01DA015133-
Referral to self-help: Clients’ and clinicians’ views, R03 DA13432Referral to self-help: Clients’ and clinicians’ views, R03 DA13432
Pathways Pathways Study SampleStudy Sample (N = 354) (N = 354)::SummarySummary (see handouts) (see handouts)
Primarily members of inner-city ethnic, underserved minoritiesPrimarily members of inner-city ethnic, underserved minorities
Long & severe history of (primarily) crack and/or heroin useLong & severe history of (primarily) crack and/or heroin use
Almost all are polysubstance usersAlmost all are polysubstance users
Self-identified as ‘in recovery’ from one month to 10+ yearsSelf-identified as ‘in recovery’ from one month to 10+ years
30% HepC+ and 22% HIV+30% HepC+ and 22% HIV+
Almost all have used formal addiction treatment services Almost all have used formal addiction treatment services andand 12-step fellowships12-step fellowships
Key PointsKey Points
Need to make recovery a bona fide topic of researchNeed to make recovery a bona fide topic of research
Need to adopt long-term ‘career’ perspectiveNeed to adopt long-term ‘career’ perspective
Need to identify Need to identify multiplicity of recovery experiences, paths and multiplicity of recovery experiences, paths and chronological patterns (stages) and their determinants:chronological patterns (stages) and their determinants:
Recovery challenges, resources and unmet needs Recovery challenges, resources and unmet needs associated with the initiation, consolidation and associated with the initiation, consolidation and maintenance of recovery maintenance of recovery
66
Why study the Why study the recovery processrecovery process??
Why study the recovery processWhy study the recovery process??
The prevalent view of addiction is that it is, for many, a lifelong ‘chronic’ The prevalent view of addiction is that it is, for many, a lifelong ‘chronic’ disorder disorder
However, However, stable stable recovery is a reality for millions of peoplerecovery is a reality for millions of people
We know a great deal about active addiction patterns - there are large We know a great deal about active addiction patterns - there are large databases about lifetime, past year and past month substance usedatabases about lifetime, past year and past month substance use
We know about the process of We know about the process of recovery initiationrecovery initiation through treatment through treatment evaluation studiesevaluation studies
““Looking at treatment to understand recovery is like looking at birth to Looking at treatment to understand recovery is like looking at birth to understand life” (Bill White)understand life” (Bill White)
Why study the recovery processWhy study the recovery process? ? [2][2]
Recovery from a chronic disorder is process unfolding over time
We know little about temporal patterns of recovery over time or about predictors of long-term recovery (recovery consolidation and maintenance)
We know virtually nothing about the size or profile of the recovering community in the US
Worse, we know little about how recovering persons achieve or maintain their status over time
The drug field lags far behind the alcoholism field where several long-term and prevalence estimates of recovery have been conducted (e.g., Vaillant as well as Dawson 2005) - although more is needed.
Why study the recovery processWhy study the recovery process? ? [3][3]
Active addiction has multiple, high costs to the individual and to society (ref. Active addiction has multiple, high costs to the individual and to society (ref. High HIV+ and HepC+ rates)High HIV+ and HepC+ rates)
Understanding the recovery process and its determinants:Understanding the recovery process and its determinants:
Inform program development and service deliveryInform program development and service deliveryInform about needed supports and resources for the recovery community Inform about needed supports and resources for the recovery community
Learning from the experiences of the recovering community can contribute to:Learning from the experiences of the recovering community can contribute to:
Give hope to active addicts and their familyGive hope to active addicts and their familyCounterbalance the stigma of active addiction that leads to discrimination Counterbalance the stigma of active addiction that leads to discrimination for recovering persons –e.g., in the work placefor recovering persons –e.g., in the work place
1010
“One of the great surprises of longitudinal research is that you discover that people do recover”
George Vaillant
1111
What does What does ‘Recovery’ mean?‘Recovery’ mean?
3%
8%
62%
22%
Public’s Perception Of “In Recovery”Public’s Perception Of “In Recovery”From Faces & Voices of Recovery – April 2004/Hart Research and Coldwater Corporation [National Random phone survey N = 801]
When you hear the word “recovery, as in “This person is in recovery from an addiction,” what does “recovery” mean?
Person is free from addiction/no longer
uses D&A
Person is trying to stop using D&A
Person has been damaged by D&A
Person has mental illness
1.4
1.7
3.1
8
85.8
Moderate/controlleduse of any drug and
alcohol
Other
No hard drugs, otherD&A OK
Not ANY drug, somealcohol
Being drug-free (Nouse of any D&A)
Pathways ParticipantsPathways Participants Recovery definition Recovery definition
Recovery definition: so what?Recovery definition: so what?
While the recovery community largely defines ‘recovery’ as the While the recovery community largely defines ‘recovery’ as the achievementachievement of drug-free status, two-thirds of the the general of drug-free status, two-thirds of the the general public defines it as an public defines it as an attemptattempt to become drug-free (can it be to become drug-free (can it be achieved?)…achieved?)…
This suggests that more work needs to be done to inform the This suggests that more work needs to be done to inform the public that public that achievingachieving drug-free recovery is a realitydrug-free recovery is a reality
Recovery patternsRecovery patterns
Few long-term studies on recovery (<2 yrs)Few long-term studies on recovery (<2 yrs)
Most conducted among Most conducted among alcohol-dependentalcohol-dependent persons persons (e.g. Vaillant)(e.g. Vaillant)
Findings suggest that although the course of Findings suggest that although the course of recovery varies across individuals, the recovery varies across individuals, the likelihood of likelihood of sustained recovery increases over timesustained recovery increases over time (I.e., the risk (I.e., the risk of relapse decreases over time)of relapse decreases over time)
Sustained drug-free recovery at F1 as a function of Sustained drug-free recovery at F1 as a function of baseline recovery stage (N = 287)baseline recovery stage (N = 287)
Pathways participantsPathways participants
43.6
57.5
86.4 84.2
Sustained recoveryF1
43.6 57.5 86.4 84.2
Under 6 mo.
Six to 18 mos.
18 to 36 mos
Three+ years
Recovery patternsRecovery patterns
Evidence that the risk of relapse remains, even after Evidence that the risk of relapse remains, even after several years of abstinence…. several years of abstinence….
We examined retrospective recovery patterns among We examined retrospective recovery patterns among Pathways participantsPathways participants
Yes71%
Pathways to Long-Term AbstinencePathways to Long-Term Abstinence Relapse HistoryRelapse History (n=354)(n=354)
Since starting regular drug use, did you ever have one or more period (s)
of complete abstinence of one month or longer followed by return
to active addiction?
Relapse HistoryRelapse HistoryNumber of clean periods followed by return to active addictionb
Over 50% reported 4 or more abstinent periods followed by return to active addiction
Range 1 to 90 Mean = 7.56; Std dev= 10.6bAmong those who report one or more such periods: N=248- 5 “don’t know”
20 & over10%
Ten to 1917%
Six to nine7%
Four to five16%
Three11%
Two 22%
One17%
Length of Length of longestlongest ‘clean’ period ‘clean’ period before return to active addictionbefore return to active addictionb
50% had one or more clean periods of one year or longer- 28% had one of 3 years or longer before slip/relapse
Ranges= 1 to 120 Mean = 23.6 Std dev= 27.9B Among those who report one or more such periods: N=253
12.3
15.5
18.3
17.1
8.3
11.5
17.0
0 5 10 15 20
Five years and over
Three to under five years
Two to under three years
One to under two years
Six to eleven months
Two to five months
One month
Length of relapse after longest Length of relapse after longest clean period clean period b
63% of respondents say relapse lasted over one year
Range = > one month to 16 yrs Mean =36.3; Std dev= 49.3 b Among those who report one or more such periods: N=253
18%
20%
11%
16%
6% 4%25%
5 yrs & over2 to under 5 yrs
One to under 2 yrsSix to 11 mons.
Two to 5 mos.One month
Under one month
Relapse patterns: RelevanceRelapse patterns: Relevance
One quarter of pathways participants are HIV+, 30% HepC+One quarter of pathways participants are HIV+, 30% HepC+
Increased likelihood of risky behaviors (e.g., unprotected sex, Increased likelihood of risky behaviors (e.g., unprotected sex, multiple partners) during active addictionmultiple partners) during active addiction
NEED TO ELUCIDATE BARRIERS TO SUSTAINED RECOVERY NEED TO ELUCIDATE BARRIERS TO SUSTAINED RECOVERY AND SUCCESFUL STRATEGIES TO SUSTAIN RECOVERYAND SUCCESFUL STRATEGIES TO SUSTAIN RECOVERY
Relapse after RecoveryRelapse after Recoverybb
What got you back to using? Top answers (<10%)What got you back to using? Top answers (<10%)
10.3
12.3
32.2
38.9
0 5 10 15 20 25 30 35 40 45
B Among those who report one or more such periods: N=253
Relapse after longest clean periodRelapse after longest clean periodbb
Lessons learnt Top answers (<10%)Lessons learnt Top answers (<10%)
B Among those who report one or more such periods: N=253
10.3
11.5
15.1
18.3
18.7
21.8
I am an addict/can't use socially
Need to address underlyingissues/express feelings
Cannot recover without support
Learn about/stay away from triggers
Being clean is a positive/drugsnegative/bad place to be
Must want recovery/work on itcontinously/make it a priority
Strategies to deal with recovery challengesStrategies to deal with recovery challengesPathways participantsPathways participantscc
Seeking support and staying focused Seeking support and staying focused
Distraction6%
Seek help/support, Talk about pb
44%
Stay focused42%
Mediate/pray8%
C Among those who report a challenge
Recovery patterns summaryRecovery patterns summary
The risk of relapse remains well into the recovery processThe risk of relapse remains well into the recovery process
Stress, exposure to triggers, temptations/urges, and belief that Stress, exposure to triggers, temptations/urges, and belief that one can control drug use are recovery challenges and key one can control drug use are recovery challenges and key factors in return to active addictionfactors in return to active addiction
Making recovery a priority, staying focused on recovery and Making recovery a priority, staying focused on recovery and seeking support are identified as helpful strategiesseeking support are identified as helpful strategies
2727
Recovery CapitalRecovery Capital
Recovery CapitalRecovery CapitalRecovery capital refers to the amount and quality of Internal and Recovery capital refers to the amount and quality of Internal and external resources that one can bring to bear to initiate and sustain external resources that one can bring to bear to initiate and sustain recovery from addictionrecovery from addiction
A number of factors have been identified as predictors of recovery A number of factors have been identified as predictors of recovery in short-term studies and constitute recovery capitalin short-term studies and constitute recovery capital
They include:They include:
Cognitive recovery readinessCognitive recovery readiness
Participation in 12-step fellowshipsParticipation in 12-step fellowships
Faith/spirituality/life meaningFaith/spirituality/life meaning
2929
Recovery CapitalRecovery Capital
Cognitive recovery readinessCognitive recovery readiness
Cognitive recovery readinessCognitive recovery readinessCognitive domains associated with enhanced recovery outcomes in Cognitive domains associated with enhanced recovery outcomes in process research include: process research include:
Generic processes common to several addiction treatment Generic processes common to several addiction treatment orientations such orientations such as drug abstinence self-efficacy, motivation and as drug abstinence self-efficacy, motivation and copingcoping; and; and
Processes that are unique to the disease (Minnesota) model:Processes that are unique to the disease (Minnesota) model:Embracing the disease view of addiction as a lifelong disorderEmbracing the disease view of addiction as a lifelong disorderAdmitting powerlessness over drugs and alcohol, Admitting powerlessness over drugs and alcohol, Accepting the need for/believing in a Higher power, Accepting the need for/believing in a Higher power, Commitment to 12-step fellowships (intention to attend 12-Commitment to 12-step fellowships (intention to attend 12-step groups), andstep groups), and identifying with others in recovery. identifying with others in recovery.
Increasing/higher levels of these cognitive processes found to be Increasing/higher levels of these cognitive processes found to be associated with better subsequent substance use outcomes. associated with better subsequent substance use outcomes.
Cognitive Recovery Readiness Cognitive Recovery Readiness across Stages of Changeacross Stages of Change
Disease model beliefs + motivation and coping
(i.e., all but self-efficacy)
STAGE OF CHANGE
ActionContemplationPrecontemplation
Mea
n sc
ore
(sca
le r
ange
= 1
to 5
) 4.2
4.0
3.8
3.6
3.4
Asbtinence
self-efficacy
Recovery readiness*
Cognitive Recovery Readiness Cognitive Recovery Readiness as a function of help seeking careeras a function of help seeking career
Prior treatment here – same trend with prior 12-step attendancePrior treatment here – same trend with prior 12-step attendance
Abstinence
self-efficacy
Recovery readiness*
NUMBER PRIOR TREATMENT EPISODES
10+5-93-4TwoOneNone
Mea
n sc
ore
5.0
4.5
4.0
3.5
3.0
2.5
* Disease model beliefs + motivation and coping
(i.e., all but self-efficacy)
So, Cognitive recovery readiness…So, Cognitive recovery readiness…
Increases over stages of change
Increases as a function of cumulative recovery help seeking (treatment and 12-step)
3434
Recovery CapitalRecovery Capital
12-step fellowships12-step fellowships
BackgroundBackground
• In the United States, 12-step groups (e.g., Alcoholics and In the United States, 12-step groups (e.g., Alcoholics and Narcotics Anonymous) are both Narcotics Anonymous) are both the most prevalent types of the most prevalent types of self-help groups and the most common source of helpself-help groups and the most common source of help sought sought by people with substance abuse problems.by people with substance abuse problems.
• Participation in 12-step groups during and after formal Participation in 12-step groups during and after formal treatment associated with reduced rates of substance usetreatment associated with reduced rates of substance use
• Concurrent use of 12-step and formal treatment has been Concurrent use of 12-step and formal treatment has been shown to have additive effects shown to have additive effects
12-step affiliation and sustained recovery12-step affiliation and sustained recovery
Effectiveness: Twelve step affiliation (attendance and Effectiveness: Twelve step affiliation (attendance and involvement) significantly associated with involvement) significantly associated with subsequent positive (sustained) recovery outcome…subsequent positive (sustained) recovery outcome…
Effectiveness: Sustained abstinent recovery at F1 as Effectiveness: Sustained abstinent recovery at F1 as a function of baseline level of 12-step attendance a function of baseline level of 12-step attendance
and affiliationand affiliation
Consider self member
Stepwork
Attended 12-step
past yr
Sustained abstinent recovery at F1
Sustained recoveryNo
.8
.7
.6
.5
.4
.3
3838
12-step attendance: 12-step attendance: Patterns and attritionPatterns and attrition
12-step Attendance patterns12-step Attendance patternsAftercare participants Aftercare participants (N = 314)(N = 314)
Never attended
19%
Attended past year
58%
Disengaged23%
12-step attrition: Ever dropped out?12-step attrition: Ever dropped out?
85%91%
0%
25%
50%
75%
100%
NarcoticsAnonymous
AlcholicsAnonymous
Since you fist started attending, have you ever stopped attended for one month or longer? (yes)
4141
Perceived helpfulness Perceived helpfulness and benefits of 12-step and benefits of 12-step
groupsgroups
Attitudes about 12-step among Drug Attitudes about 12-step among Drug Treatment patients Treatment patients e
7.86
8.02
8.70
7.4 7.6 7.8 8 8.2 8.4 8.6 8.8
Importance of12-step inrecoveryprocess
Importance of12-step intreatment
Helpfulness of12-step
e Scale range from 0 to 10
59
33
4
3
41
58
4
8
0 20 40 60
Promotes recovery
Support/acceptance/fe
llo...
To make fri
ends, to check ..
Step work, spirit
uality
Narcotic Anonymous
Alc. Anonymous
Reasons for 12-step attendanceReasons for 12-step attendanceff ,g ,g
F among ‘ever’ attenders; g Add to < 100% because up to 3 answers were coded
Quandary: Quandary: 12-step attrition and non-affiliation12-step attrition and non-affiliation
12-step fellowships generally viewed as helpful and beneficial 12-step fellowships generally viewed as helpful and beneficial to recoveryto recovery
Yet, some never attend and many disaffiliate over timeYet, some never attend and many disaffiliate over time
One of the most important tasks for clinicians is to foster One of the most important tasks for clinicians is to foster stable engagement in 12-step groups to facilitate patients’ stable engagement in 12-step groups to facilitate patients’ transition into the post-treatment phase of recovery. transition into the post-treatment phase of recovery.
What are some of the reasons why substance users do not What are some of the reasons why substance users do not attend/leave 12-step?attend/leave 12-step?
4545
Obstacles to 12-step Obstacles to 12-step affiliation and reasons affiliation and reasons
for non-attendancefor non-attendance
Why did you stop attending 12-step?Why did you stop attending 12-step?(longest interrupted period)(longest interrupted period)gg
3326 25
15 13 5
G Add to < 100% because up to 3 answers were coded
Observation…Observation…
Reasons cited for not attending 12-step groups mirror the Reasons cited for not attending 12-step groups mirror the lessons learnt from relapse and helpful strategies to recover:lessons learnt from relapse and helpful strategies to recover:
Don’t want to stop vs. make recovery a priorityDon’t want to stop vs. make recovery a priority
Can do it on my own vs. seek supportCan do it on my own vs. seek support
THIS SUGGESTS THAT MOTIVATION AND ACCEPTING NEED THIS SUGGESTS THAT MOTIVATION AND ACCEPTING NEED FOR/SEEKING SUPPORT FOR RECOVERY ARE CRITICAL FOR/SEEKING SUPPORT FOR RECOVERY ARE CRITICAL
4848
Recovery CapitalRecovery Capital
Spirituality, Faith and Life meaningSpirituality, Faith and Life meaning
Baseline Spirituality, Religiosity, Life meaning Baseline Spirituality, Religiosity, Life meaning and Recovery @ F1and Recovery @ F1
Sustained abstinent recovery at F1
YesNo
Me
an
6.0
5.5
5.0
4.5
4.0
3.5
3.0
2.5
Spiritual well-being
Life meaning
Religiosity
Pathways PilotPathways PilotSpirituality and religion as Recovery support (N=52)Spirituality and religion as Recovery support (N=52)
2
8
10
12
14
16
33
34
38
0 5 10 15 20 25 30 35 40
Community invoolvment,volunteer work/service
Surrender/admittedpowerlessness
None
God (non-specific)
Support from peers
Spiritualawakening/experience
Spiritual God/HigherPower/spirituality
12-step recovery program andfellowship
Organized religion, church
h Adds up to < 100% because up to 3 answers were coded
Describe any religious/spiritual experience/ support that you have had as a significant part of your recoveryh
Pathways to Long-Term AbstinencePathways to Long-Term Abstinence Sources of strength and support in recoverySources of strength and support in recoveryaa
7
11
17
18
43
53
53
0 10 20 30 40 50 60 70 80 90 100
So, spirituality/religion…So, spirituality/religion…
Cited as critical source of recovery support Cited as critical source of recovery support
Associated with sustained recovery over timeAssociated with sustained recovery over time
5353
Why do substance users Why do substance users seek recovery?seek recovery?
Pathways to Long-Term AbstinencePathways to Long-Term AbstinenceFactors Associated with Decision to QuitFactors Associated with Decision to Quit
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.”
Recovery: The hard road to a better life?Recovery: The hard road to a better life?
Many recovering substance users report that they stopped using Many recovering substance users report that they stopped using drugs because they wanted a better life. drugs because they wanted a better life.
They see initiating recovery as the path to a better lifeThey see initiating recovery as the path to a better life
It is a challenging and stressful path for mostIt is a challenging and stressful path for most
We conducted a study that addressed two questionsWe conducted a study that addressed two questions
First: First: Does quality of life improve as recovery Does quality of life improve as recovery progresses? progresses?
Stress and Life Satisfaction as a Stress and Life Satisfaction as a Function of Length of RecoveryFunction of Length of Recovery (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
Does recovery capital buffer stress Does recovery capital buffer stress among persons in recovery?among persons in recovery?
Stress frequently cited as a relapse triggerStress frequently cited as a relapse trigger
Second question: Do factors previously identified separately as Second question: Do factors previously identified separately as buffering stress or promoting stable recovery contribute to buffering stress or promoting stable recovery contribute to enhancing QOL among recovering personsenhancing QOL among recovering persons
We tested a model that hypothesized that We tested a model that hypothesized that RECOVERY RECOVERY CAPITALCAPITAL -social support, spirituality, life meaning, religious -social support, spirituality, life meaning, religious practices, and affiliation with 12-step fellowships - practices, and affiliation with 12-step fellowships - buffers buffers stress and enhance quality of life satisfaction.stress and enhance quality of life satisfaction.
We found…We found…
Recovery capital: Buffering Stress Recovery capital: Buffering Stress and Enhancing Quality of Life in recoveryand Enhancing Quality of Life in recovery jj ( (N = 354)N = 354)
Stress
Spirituality 17%
General Social suprt 9.6%
Length of recovery 9.1%
Religiousness 8.5%
Recovery support 7.3%
Life meaning 5.6%
12-step involvement 3.5%
12-step attendance 0
Quality of life
jj All betas p<.001 except 12-step attendance
RECOVERY CAPITAL ACCOUNTS FOR 60.6% OF VARIANCE IN QOLRECOVERY CAPITAL ACCOUNTS FOR 60.6% OF VARIANCE IN QOL
Recovery capital as predictor of Recovery capital as predictor of sustained abstinent recovery at F1sustained abstinent recovery at F1
We conducted a preliminary examination of predictors of sustained abstinent recovery We conducted a preliminary examination of predictors of sustained abstinent recovery at F1 to determine whether the same or different factors predict sustained recovery at at F1 to determine whether the same or different factors predict sustained recovery at different stages of the processdifferent stages of the processMultiple regression analyses were conducted on the whole sample and on each of the Multiple regression analyses were conducted on the whole sample and on each of the four baseline recovery stage groupsfour baseline recovery stage groupsHypothesized baseline predictors of sustained abstinent recovery @ F1:Hypothesized baseline predictors of sustained abstinent recovery @ F1:
Lifetime severityLifetime severityLength of recovery @ baseLength of recovery @ baseCommitment to abstinenceCommitment to abstinenceSelf efficacySelf efficacy12-step involvement12-step involvementEmbracement disease modelEmbracement disease model12-step attendance past yr12-step attendance past yrRecovery supportRecovery supportSpiritual well-beingSpiritual well-beingReligiosityReligiosityLife meaningLife meaningLife satisfaction Life satisfaction Stress past monthStress past month
39%
21%
21%
27%
Under 6 mos.
6 to 18 mos.
18 to 36 mo.
Three+ yrs
Predictors of sustained Predictors of sustained recovery @ F1: recovery @ F1: Total sample and baseline recovery stages Total sample and baseline recovery stages N = 287N = 287
Predictors of sustained recovery appear to differ across recovery stages…Predictors of sustained recovery appear to differ across recovery stages…
TotalTotal > 6 months> 6 months 6 to 18 mos.6 to 18 mos. 18 to 36 mos. 18 to 36 mos. 3 yrs +3 yrs +
% variance explained% variance explained 15%15% 23%23% 32%32% 12%12% 15%15% Lifetime severityLifetime severity xx xx nsns xx nsnsLength of recovery @ baseLength of recovery @ base xx xx xx nsns nsnsCommitment to abstinenceCommitment to abstinence nsns nsns xx nsns xxEmbracement disease modelEmbracement disease model nsns xx nsns nsns nsns12-step attendance pst yr12-step attendance pst yr nsns xx nsns nsns nsnsRecovery supportRecovery support nsns xx nsns nsns nsnsReligiosityReligiosity nsns nsns nsns xx xx
Life meaningLife meaning xx nsns nsns nsns xx
Predictors of sustained recoveryPredictors of sustained recovery
Preliminary findings suggest that different sets of factors are associated with sustained recovery at different recovery stages
Much of the variance in sustained recovery remains unexplained and much more work is needed
6262
Recovery revisited…Recovery revisited…
Beyond drug use & abstinenceBeyond drug use & abstinence
6363
““If you want to treat an illness that has no If you want to treat an illness that has no easy cure, first of all, easy cure, first of all, treat them with hopetreat them with hope””
George VaillantGeorge Vaillant
Recovery definition revisitedRecovery definition revisited Pathways participantsPathways participantsgg
How would you define "recovery from drug and alcohol use"? How would you define "recovery from drug and alcohol use"? Please be as specific as you can. [RECORD VERBATIM]Please be as specific as you can. [RECORD VERBATIM]
RECOVERY GOES BEYOND SUBSTANCE USERECOVERY GOES BEYOND SUBSTANCE USE
24
24
31
72
0 10 20 30 40 50 60 70 80
Dealing with issues/seeking help
Lifelong process/working on self
Total abstinence
Better life/new life
G Add to < 100% because up to 3 answers were coded
Positive aspects of recoveryPositive aspects of recovery Pathways participantsPathways participantsgg
9
10
17
21
49
62
0 10 20 30 40 50 60 70
G Add to < 100% because up to 3 answers were coded
Integration of FindingsIntegration of Findings
Achieving sustained recovery is a reality Achieving sustained recovery is a reality
Recovery appears to be the road to a better life Recovery appears to be the road to a better life
There are many challenges along the way: stress, urges to use, denial of problemThere are many challenges along the way: stress, urges to use, denial of problem
There are potentially costly slips and relapses along the wayThere are potentially costly slips and relapses along the way
Keeping focused on recovery, learning to deal with stress, and seeking support are Keeping focused on recovery, learning to deal with stress, and seeking support are key to maintaining recoverykey to maintaining recovery
This translates into the need for ‘recovery capital’: motivation, accepting the problem This translates into the need for ‘recovery capital’: motivation, accepting the problem and working on it (12-step ideology), seeking support from peers (e.g., 12-step and working on it (12-step ideology), seeking support from peers (e.g., 12-step fellowships), faith, and a sense of meaning/purposefellowships), faith, and a sense of meaning/purpose
Although recovery in the US is largely defined as “abstinence from all drugs and Although recovery in the US is largely defined as “abstinence from all drugs and alcohol”, the recovery experience goes beyond substance use and represents a new alcohol”, the recovery experience goes beyond substance use and represents a new life, a better life, new hopes and opportunitieslife, a better life, new hopes and opportunities
Preliminary evidence indicates that different factors are critical to recovery at different Preliminary evidence indicates that different factors are critical to recovery at different ‘stages’ ‘stages’
6767
Looking forward…Looking forward…
MEASUREMENT and RESEARCH ISSUESMEASUREMENT and RESEARCH ISSUES
Defining RecoveryDefining RecoveryIs recovery a time-limited event (a state) or a time-extending process? If addiction is a Is recovery a time-limited event (a state) or a time-extending process? If addiction is a chronic disorder, recovery may be a process unfolding through (below) non mutually chronic disorder, recovery may be a process unfolding through (below) non mutually exclusive stages – from partial to full remission?exclusive stages – from partial to full remission?
When is recovery achieved? Under what circumstances is it lost or brought to When is recovery achieved? Under what circumstances is it lost or brought to completion?completion?
DSM-IV-R – Possible recovery stages from partial to full remissionDSM-IV-R – Possible recovery stages from partial to full remissionSub- clinical:Sub- clinical: Past year user who d Past year user who does not meet the DSM-IVR criteria for dependence oes not meet the DSM-IVR criteria for dependence butbut reported 1+ symptoms of either abuse or dependence? reported 1+ symptoms of either abuse or dependence?
Problematic use:Problematic use: Past-year risk user (see above) with no symptoms of either abuse Past-year risk user (see above) with no symptoms of either abuse or dependence in the past 12 months?or dependence in the past 12 months?
Non- problematic use:Non- problematic use: Past year substance user with no symptoms of either abuse Past year substance user with no symptoms of either abuse or dependence and not classified as a past-year risk user? or dependence and not classified as a past-year risk user?
No use:No use: No past year substance use (complete abstinence)? No past year substance use (complete abstinence)?
Investigating Recovery: How?Investigating Recovery: How?
The empirical investigation of the recovery experience over time The empirical investigation of the recovery experience over time requires requires methods that differ from those typically used when methods that differ from those typically used when conducting treatment evaluation studiesconducting treatment evaluation studies. .
For example….For example….
RECRUITMENT RECRUITMENT Persons in recovery are “from all walks of life.”Persons in recovery are “from all walks of life.”Recruiting a representative sample of recovering persons Recruiting a representative sample of recovering persons requires strategies that cast a wide net across ethnic groups, requires strategies that cast a wide net across ethnic groups, social strata, substance use histories and recovery paths. social strata, substance use histories and recovery paths. Media advertisementMedia advertisement has been the most frequently used and the has been the most frequently used and the most effective strategy for recruiting diversified samples of most effective strategy for recruiting diversified samples of recovering persons (see handout)recovering persons (see handout)
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We’ve only just begun…We’ve only just begun…
Where do we go from here?Where do we go from here?
Toward a Recovery-Oriented Research AgendaToward a Recovery-Oriented Research Agenda
1.1. Use a telescope, not a microscope (George Vaillant)Use a telescope, not a microscope (George Vaillant) – I..e.,
Adopt a long-term, natural history ‘career’ perspective to elucidate:Adopt a long-term, natural history ‘career’ perspective to elucidate:Multiplicity of recovery experiences, paths and chronological patterns (stages) Multiplicity of recovery experiences, paths and chronological patterns (stages) Determinants (promoting/hindering factors) of these paths and patterns over Determinants (promoting/hindering factors) of these paths and patterns over time time Among subgroups as the recovery experience/paths/needs may differ: e.g, Among subgroups as the recovery experience/paths/needs may differ: e.g, gender, ethnicity and age groups, HIV+, dual-diagnosis, gender, ethnicity and age groups, HIV+, dual-diagnosis, high/low problem high/low problem severity, high/low recovery capitalseverity, high/low recovery capitalAcross cultures where different socio-political views of addiction and different Across cultures where different socio-political views of addiction and different models/options of service delivery prevail models/options of service delivery prevail (‘universal’ and culture-specific (‘universal’ and culture-specific factors)factors)
2. 2. Achieve consensus on how to define and measure recoveryAchieve consensus on how to define and measure recovery In terms of substance use; and inIn terms of substance use; and in Global health, e.g., physical, emotional, relational, and occupational health and Global health, e.g., physical, emotional, relational, and occupational health and
responsible citizenshipresponsible citizenship
Toward a Recovery-Oriented Research AgendaToward a Recovery-Oriented Research Agenda
3. 3. Identify challenges, professional & indigenous resources and unmet Identify challenges, professional & indigenous resources and unmet needs associated with the initiation, consolidation and maintenance of needs associated with the initiation, consolidation and maintenance of recovery recovery
e.g., What sources of support are being used in addition to those e.g., What sources of support are being used in addition to those previously identified (treatment, 12-step) such as faith, community previously identified (treatment, 12-step) such as faith, community involvementinvolvementRole of family in Role of family in the individual recovery process as well as stages the individual recovery process as well as stages of family recovery (family as whole and family subsystems)of family recovery (family as whole and family subsystems)Role of stigma as obstacle to recovery Role of stigma as obstacle to recovery initiation and maintenanceinitiation and maintenance
4. 4. Assess the long-term consequences of various recovery pathsAssess the long-term consequences of various recovery paths (e.g., (e.g., psychosocial and cognitive/brain functioning in medically-assisted vs. psychosocial and cognitive/brain functioning in medically-assisted vs. drug-free recovery) drug-free recovery)
5. 5. Integrate empirical findings about the recovery process into existing Integrate empirical findings about the recovery process into existing
knowledge about addiction to promote:knowledge about addiction to promote: A paradigm shift in service delivery and assessment from the A paradigm shift in service delivery and assessment from the
current ‘acute’ model to sustained recovery managementcurrent ‘acute’ model to sustained recovery management• Societal awareness about the reality and hope of recovery and the Societal awareness about the reality and hope of recovery and the
multiple pathways to long-term recoverymultiple pathways to long-term recovery