Exploring the recovery process: Patterns, supports, challenges and future directions

1
Exploring the recovery process Patterns,
supports, challenges and future directions

• Alexandre B. Laudet
• Presented at the Seminar Series of the Division
  of Epidemiology, Services and Prevention Research
  (DESPR)
  
• National Institute on Drug Abuse (NIDA)
• April 20, 2005
• Center for the Study of Addiction and
  RecoveryNational Development and Research
  Institutes, Inc.
  
• Correspondence laudet_at_ndri.org

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In collaboration with

• Co-Investigators William L. White,
  Chestnut//Lighthouse
  
• Gordon Storey, Self-Help Addiction Resource
  Center (SHARC)
  
• Statistician Keith Morgen, NDRI
• Operations Virginia Stanick, and Marie Marthol,
  NDRI
  
• Field Jeffrey Becker, Wanda Bonilla, Nadina
  Correa, Una Cruz, Doug Goldsmith, , Myrta
  Hernandez, Yolanda Jones, Vanessa Rodriguez,
  Scott Smith, Luis Torres, NDRI
• Design Evette McCoy, NDRI

3
Background

• This presentation draws on prospective and
  retrospective findings from three NIDA-F studies
  using both quantitative and qualitative methods
  to explore the recovery experience over time as
  well as factors that promote and hinder the
  process.
• The studies were/are conducted among inner-city
  participants in New York City (details in
  handouts)
  
• Pathways to long-term abstinence Self-help
  processes, R01DA14409
  
• Twelve-step as aftercare predictors and
  effectiveness, R01DA015133-
  
• Referral to self-help Clients and clinicians
  views, R03 DA13432
  

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Pathways Study Sample (N 354)Summary (see
handouts)

• Primarily members of inner-city ethnic,
  underserved minorities
  
• Long severe history of (primarily) crack and/or
  heroin use
  
• Almost all are polysubstance users
• Self-identified as in recovery from one month
  to 10 years
  
• 30 HepC and 22 HIV
• Almost all have used formal addiction treatment
  services and 12-step fellowships

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Key Points

• Need to make recovery a bona fide topic of
  research
  
• Need to adopt long-term career perspective
• Need to identify multiplicity of recovery
  experiences, paths and chronological patterns
  (stages) and their determinants
  
• Recovery challenges, resources and unmet needs
  associated with the initiation, consolidation and
  maintenance of recovery
  

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Why study the recovery process?
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Why study the recovery process?

• The prevalent view of addiction is that it is,
  for many, a lifelong chronic disorder
  
• However, stable recovery is a reality for
  millions of people
  
• We know a great deal about active addiction
  patterns - there are large databases about
  lifetime, past year and past month substance use
  
• We know about the process of recovery initiation
  through treatment evaluation studies
  
• Looking at treatment to understand recovery is
  like looking at birth to understand life (Bill
  White)
  

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Why study the recovery process? 2

•      

Recovery from a chronic disorder is process
unfolding over time We know little about tempor
al patterns of recovery over time or about
predictors of long-term recovery (recovery
consolidation and maintenance)
We know virtually nothing about the size or prof
ile of the recovering community in the US
Worse, we know little about how recovering perso
ns achieve or maintain their status over time
The drug field lags far behind the alcoholism fi
eld where several long-term and prevalence
estimates of recovery have been conducted (e.g.,
Vaillant as well as Dawson 2005) - although more
is needed.
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Why study the recovery process? 3

• Active addiction has multiple, high costs to the
  individual and to society (ref. High HIV and
  HepC rates)
  
• Understanding the recovery process and its
  determinants
  
• Inform program development and service delivery
• Inform about needed supports and resources for
  the recovery community
  
• Learning from the experiences of the recovering
  community can contribute to
  
• Give hope to active addicts and their family
• Counterbalance the stigma of active addiction
  that leads to discrimination for recovering
  persons e.g., in the work place
  
•  

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One of the great surprises of longitudinal
research is that you discover that people do
recover

• George Vaillant

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What does Recovery mean?
12
Publics Perception Of In RecoveryFrom 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
DA Person is trying to stop using DA Person h
as been damaged by DA Person has mental illne
ss
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Pathways Participants Recovery definition
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Recovery definition so what?

• While the recovery community largely defines
  recovery as the achievement of drug-free
  status, two-thirds of the the general public
  defines it as an attempt to become drug-free (can
  it be achieved?)
• This suggests that more work needs to be done to
  inform the public that achieving drug-free
  recovery is a reality

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Recovery patterns

• Few long-term studies on recovery (
• Most conducted among alcohol-dependent persons
  (e.g. Vaillant)
  
• Findings suggest that although the course of
  recovery varies across individuals, the
  likelihood of sustained recovery increases over
  time (I.e., the risk of relapse decreases over
  time)

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Sustained drug-free recovery at F1 as a function
of baseline recovery stage (N 287)Pathways
participants
17
Recovery patterns

• Evidence that the risk of relapse remains, even
  after several years of abstinence.
  
• We examined retrospective recovery patterns among
  Pathways participants
  

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Pathways to Long-Term Abstinence Relapse History
(n354)
Since starting regular drug use, did you ever
have one or more period (s) of complete abstinen
ce of one month or longer followed by return
to active addiction?
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Relapse History
Number of clean periods followed by return to
active addictionb Over 50 reported 4 or more abs
tinent periods followed by return to active addi
ction
Range 1 to 90 Mean 7.56 Std dev 10.6
bAmong those who report one or more such periods
N248- 5 dont know
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Length of longest clean period before 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
27.9 B Among those who report one or more such pe
riods N253
21
Length of relapse after longest 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 s
uch periods N253
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Relapse patterns Relevance

• One quarter of pathways participants are HIV,
  30 HepC
  
• Increased likelihood of risky behaviors (e.g.,
  unprotected sex, multiple partners) during active
  addiction
  
• NEED TO ELUCIDATE BARRIERS TO SUSTAINED RECOVERY
  AND SUCCESFUL STRATEGIES TO SUSTAIN RECOVERY
  

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Relapse after Recoveryb What got you back to usi
ng? Top answers (
B Among those who report one or more such
periods N253
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Relapse after longest clean periodb
Lessons learnt Top answers (
B Among those who report one or more such
periods N253
25
Strategies to deal with recovery
challengesPathways participantscSeeking support
and staying focused
C Among those who report a challenge
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Recovery patterns summary

• The risk of relapse remains well into the
  recovery process
  
• Stress, exposure to triggers, temptations/urges,
  and belief that one can control drug use are
  recovery challenges and key factors in return to
  active addiction
• Making recovery a priority, staying focused on
  recovery and seeking support are identified as
  helpful strategies
  

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Recovery Capital
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Recovery Capital

• Recovery capital refers to the amount and quality
  of Internal and external resources that one can
  bring to bear to initiate and sustain recovery
  from addiction
• A number of factors have been identified as
  predictors of recovery in short-term studies and
  constitute recovery capital
  
• They include
• Cognitive recovery readiness
• Participation in 12-step fellowships
• Faith/spirituality/life meaning

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Recovery Capital

• Cognitive recovery readiness

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Cognitive recovery readiness

• Cognitive domains associated with enhanced
  recovery outcomes in process research include
  
• Generic processes common to several addiction
  treatment orientations such as drug abstinence
  self-efficacy, motivation and coping and
  
• Processes that are unique to the disease
  (Minnesota) model
  
• Embracing the disease view of addiction as a
  lifelong disorder
  
• Admitting powerlessness over drugs and alcohol,
• Accepting the need for/believing in a Higher
  power,
  
• Commitment to 12-step fellowships (intention to
  attend 12-step groups), and
  
• identifying with others in recovery.
• Increasing/higher levels of these cognitive
  processes found to be associated with better
  subsequent substance use outcomes.

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Cognitive Recovery Readiness across Stages of
Change
 
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Cognitive Recovery Readiness as a function of
help seeking careerPrior treatment here same
trend with prior 12-step attendance
 
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So, Cognitive recovery readiness

• Increases over stages of change
• Increases as a function of cumulative recovery
  help seeking (treatment and 12-step)

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Recovery Capital

• 12-step fellowships

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Background

• In the United States, 12-step groups (e.g.,
  Alcoholics and Narcotics Anonymous) are both the
  most prevalent types of self-help groups and the
  most common source of help sought by people with
  substance abuse problems.
• Participation in 12-step groups during and after
  formal treatment associated with reduced rates of
  substance use
  
• Concurrent use of 12-step and formal treatment
  has been shown to have additive effects
  

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12-step affiliation and sustained recovery

• Effectiveness Twelve step affiliation
  (attendance and involvement) significantly
  associated with subsequent positive (sustained)
  recovery outcome

37
Effectiveness Sustained abstinent recovery at F1
as a function of baseline level of 12-step
attendance and affiliation
38
12-step attendance Patterns and attrition
39
12-step Attendance patternsAftercare
participants (N 314)
40
12-step attrition Ever dropped out?
Since you fist started attending, have you ever
stopped
attended for one month or longer? (yes)
41
Perceived helpfulness and benefits of 12-step
groups
42
Attitudes about 12-step among Drug Treatment
patients e
e Scale range from 0 to 10
43
Reasons for 12-step attendancef ,g
F among ever attenders g Add to up to 3 answers were coded
44
Quandary 12-step attrition and non-affiliation

• 12-step fellowships generally viewed as helpful
  and beneficial to recovery
  
• Yet, some never attend and many disaffiliate over
  time
  
• One of the most important tasks for clinicians is
  to foster stable engagement in 12-step groups to
  facilitate patients transition into the
  post-treatment phase of recovery.
• What are some of the reasons why substance users
  do not attend/leave 12-step?
  

45
Obstacles to 12-step affiliation and reasons for
non-attendance
46
Why did you stop attending 12-step?(longest
interrupted period)g
G Add to coded

47
Observation

• Reasons cited for not attending 12-step groups
  mirror the lessons learnt from relapse and
  helpful strategies to recover
  
• Dont want to stop vs. make recovery a priority
• Can do it on my own vs. seek support
• THIS SUGGESTS THAT MOTIVATION AND ACCEPTING NEED
  FOR/SEEKING SUPPORT FOR RECOVERY ARE CRITICAL

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Recovery Capital

• Spirituality, Faith and Life meaning

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Baseline Spirituality, Religiosity, Life meaning
and Recovery _at_ F1
50
Pathways PilotSpirituality and religion as
Recovery support (N52)
Describe any religious/spiritual experience/
support that you have had as a significant part
of your recoveryh
h Adds up to coded
51
Pathways to Long-Term Abstinence Sources of
strength and support in recoverya
52
So, spirituality/religion

• Cited as critical source of recovery support
• Associated with sustained recovery over time

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Why do substance users seek recovery?
54
Pathways to Long-Term AbstinenceFactors
Associated with Decision to Quit
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.
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Recovery The hard road to a better life?

• Many recovering substance users report that they
  stopped using drugs because they wanted a better
  life.
  
• They see initiating recovery as the path to a
  better life
  
• It is a challenging and stressful path for most
• We conducted a study that addressed two questions
  
  
• First Does quality of life improve as recovery
  progresses?
  

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Stress and Life Satisfaction as a Function of
Length of Recovery (N 354)

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Does recovery capital buffer stress among persons
in recovery?

• Stress frequently cited as a relapse trigger
• Second question Do factors previously identified
  separately as buffering stress or promoting
  stable recovery contribute to enhancing QOL among
  recovering persons
• We tested a model that hypothesized that
  RECOVERY CAPITAL -social support, spirituality,
  life meaning, religious practices, and
  affiliation with 12-step fellowships - buffers
  stress and enhance quality of life satisfaction.
• We found

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Recovery capital Buffering Stress and Enhancing
Quality of Life in recovery j (N 354)
RECOVERY CAPITAL ACCOUNTS FOR 60.6 OF VARIANCE
IN QOL
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
Stress
j All betas p 59
Recovery capital as predictor of sustained
abstinent recovery at F1

• 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 different
  stages of the process
• Multiple regression analyses were conducted on
  the whole sample and on each of the four baseline
  recovery stage groups
  
• Hypothesized baseline predictors of sustained
  abstinent recovery _at_ F1
  
• Lifetime severity
• Length of recovery _at_ base
• Commitment to abstinence
• Self efficacy
• 12-step involvement
• Embracement disease model
• 12-step attendance past yr
• Recovery support
• Spiritual well-being
• Religiosity
• Life meaning
• Life satisfaction
• Stress past month

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Predictors of sustained recovery _at_ F1 Total
sample and baseline recovery stages N 287
Predictors of sustained recovery appear to differ
across recovery stages

• Total 6 months 6 to 18 mos. 18 to 36 mos. 3
  yrs
  
•  
•  
• variance explained 15 23 32 12 15
•  
• Lifetime severity x x ns x ns
• Length of recovery _at_ base x x x ns ns
• Commitment to abstinence ns ns x ns x
• Embracement disease model ns x ns ns ns
• 12-step attendance pst yr ns x ns ns ns
• Recovery support ns x ns ns ns
• Religiosity ns ns ns x x
• Life meaning x ns ns ns x
•  
•  
•  

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Predictors 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
  

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Recovery revisited

• Beyond drug use abstinence

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If you want to treat an illness that has no easy
cure, first of all, treat them with hope

• George Vaillant

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Recovery definition revisited Pathways
participantsgHow would you define "recovery from
drug and alcohol use"? Please be as specific as
you can. RECORD VERBATIMRECOVERY GOES BEYOND
SUBSTANCE USE
G Add to coded

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Positive aspects of recovery Pathways
participantsg
G Add to coded

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Integration of Findings

•  
• Achieving sustained recovery is a reality
• Recovery appears to be the road to a better life
  
  
• There are many challenges along the way stress,
  urges to use, denial of problem
  
• There are potentially costly slips and relapses
  along the way
  
• Keeping focused on recovery, learning to deal
  with stress, and seeking support are key to
  maintaining recovery
  
• 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 fellowships), faith,
  and a sense of meaning/purpose
• 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 life, a better life, new hopes
  and opportunities
• Preliminary evidence indicates that different
  factors are critical to recovery at different
  stages  

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Looking forward

• MEASUREMENT and RESEARCH ISSUES

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Defining Recovery

• 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 exclusive stages
  from partial to full remission?
• When is recovery achieved? Under what
  circumstances is it lost or brought to
  completion?
  
• DSM-IV-R Possible recovery stages from partial
  to full remission
  
• Sub- clinical Past year user who does not meet
  the DSM-IVR criteria for dependence but reported
  1 symptoms of either abuse or dependence?
  
• Problematic use Past-year risk user (see above)
  with no symptoms of either abuse or dependence in
  the past 12 months?
  
• Non- problematic use Past year substance user
  with no symptoms of either abuse or dependence
  and not classified as a past-year risk user? 
  
• No use No past year substance use (complete
  abstinence)?
  

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Investigating Recovery How?

• The empirical investigation of the recovery
  experience over time requires methods that differ
  from those typically used when conducting
  treatment evaluation studies.
• For example.
• RECRUITMENT
• Persons in recovery are from all walks of
  life.
  
• Recruiting a representative sample of recovering
  persons requires strategies that cast a wide net
  across ethnic groups, social strata, substance
  use histories and recovery paths.
• Media advertisement has been the most frequently
  used and the most effective strategy for
  recruiting diversified samples of recovering
  persons (see handout)

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Weve only just begun

• Where do we go from here?  

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Toward a Recovery-Oriented Research Agenda

•  
• 1. Use a telescope, not a microscope (George
  Vaillant) I..e.,
  
• Adopt a long-term, natural history career
  perspective to elucidate
  
• Multiplicity of recovery experiences, paths and
  chronological patterns (stages)
  
• Determinants (promoting/hindering factors) of
  these paths and patterns over time
  
• Among subgroups as the recovery
  experience/paths/needs may differ e.g, gender,
  ethnicity and age groups, HIV, dual-diagnosis,
  high/low problem severity, high/low recovery
  capital
• Across cultures where different socio-political
  views of addiction and different models/options
  of service delivery prevail (universal and
  culture-specific factors)
• 2. Achieve consensus on how to define and measure
  recovery
  
• In terms of substance use and in
• Global health, e.g., physical, emotional,
  relational, and occupational health and
  responsible citizenship
  
•  

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Toward a Recovery-Oriented Research Agenda

• 3. Identify challenges, professional indigenous
  resources and unmet needs associated with the
  initiation, consolidation and maintenance of
  recovery
• e.g., What sources of support are being used in
  addition to those previously identified
  (treatment, 12-step) such as faith, community
  involvement
• Role of family in the individual recovery process
  as well as stages of family recovery (family as
  whole and family subsystems)
  
• Role of stigma as obstacle to recovery initiation
  and maintenance
  
• 4. Assess the long-term consequences of various
  recovery paths (e.g., psychosocial and
  cognitive/brain functioning in medically-assisted
  vs. drug-free recovery)
•  
• 5. Integrate empirical findings about the
  recovery process into existing knowledge about
  addiction to promote 
  
• A paradigm shift in service delivery and
  assessment from the current acute model to
  sustained recovery management
  
• Societal awareness about the reality and hope of
  recovery and the multiple pathways to long-term
  recovery