1. Recovery – getting there and staying there
David McCartney, Clinical Lead LEAP

2. Recovery Part 1: Getting there
Do people get better?
What helps them?
What does it mean?

3. 3

4. Do people get better?

5. Recovery rates Center for Substance Abuse Treatment
Review of the scientific literature in 2009
“58% of life-course dependent users of substances will achieve lasting recovery”
The review of the evidence base commissioned by the Scottish Government in 2010 found that sustained recovery is the norm
Review of the best evidence of recovery over a life course by the Centre for Substance Abuse Treatment in 2009 found that a significant majority will achieve lasting recovery.
This is backed up by Bill White’s review of Recovery/remission rates which found that in an analysis of 276 addiction follow-up studies of adult clinical samples, the average remission/recovery rate across all studies was 47.6% and in studies published since 2000, this rose to 50.3%. (Recovery/Remission from Substance use disorders. An analysis of reported outcomes in 415 Scientific Reports, )

6. Recovery rates 276 studies (adults in clinical settings)
Average across all studies was 47.6% remission
In studies since 2000 it was 50.3% long term remission
The review of the evidence base commissioned by the Scottish Government in 2010 found that sustained recovery is the norm
Review of the best evidence of recovery over a life course by the Centre for Substance Abuse Treatment in 2009 found that a significant majority will achieve lasting recovery.
This is backed up by Bill White’s review of Recovery/remission rates which found that in an analysis of 276 addiction follow-up studies of adult clinical samples, the average remission/recovery rate across all studies was 47.6% and in studies published since 2000, this rose to 50.3%. (Recovery/Remission from Substance use disorders. An analysis of reported outcomes in 415 Scientific Reports, )
White 2012

7. Recovery rates Welsh workers’ estimate: 7% (Best)
The ‘clinical fallacy’
And yet when Dr David Best asked Welsh addiction workers how many of their clients would ever recover they reckoned about 7%. The disparity between what the evidence says and what workers in Wales believe may be explained in several ways. An overwhelming domination of harm reduction as treatment in the UK until more recent policy changes; burnout and hopelessness and the clinical fallacy (Gossop 2008) This is the phenomenon whereby people moving into abstinent recovery move out of prescribing services so that their addiction workers never get to see them ‘better’. What they do see all the time are the people who do not move on and the serial relapsers leading to the impression that people do not get better. 7

8. Recovery rates
“There is little UK-based research and the international evidence base on recovery is limited by three factors:
Much of the evidence is dated;
Much of it is based on alcohol rather than illicit drugs; and
Almost all the evidence originates from the United States.”
Research for Recovery, Scottish Government (2010)

9. Sustained recovery ‘is the norm’!
But…
Sustained recovery ‘is the norm’!
Research for Recovery, Scottish Government (2010)

10. LEAP Study 125 patients Entering treatment 2008-9
Followed up for four years
Independent researcher

11. LEAP patients at 4 years
48% all patients starting treatment abstinent from alcohol, illicit and precribed drugs
61% of all patients completing treatment abstinent

12. Do people get better?
Yes!

13. How does it happen?

14. Study of workers in the field in recovery from heroin addiction (n=108)
Why did they stop? Tired of lifestyle plus a trigger event – physical, psychological or family based
Why did they stay stopped? Other people
Moving away from using networks
Finding supportive non-using recovery networks
Best et al (2008) 14

15. Building Recovery capital15

17. Asking for help Treatment (hundreds of studies)
Mutual aid (hundreds of studies)
Families

18. Aftercare Less relapse in clients attending aftercare post-treatment
Less return to crime*
But ‘only a minority of programmes… provide aftercare’**
Mutual aid can be seen as a form of aftercare**
*Wexler et al, 1999
**Research for Recovery 2010

19. Recovery communities Growing Build recovery capital
In one study*, mutual aid and other community support was twice as effective as standard aftercare in reducing readmission to hospital for mental health
*Edmunson et al, 1984

20. Local recovery communities Lothian
Mutual aid (120)
Serenity cafe
Horizons Cafe
Cyrenians Hub 20

21. But who is responsible for what?
Treatment: ‘to help people stop using’
Treatment: address mental and physical co-morbidity
Recovery community: ‘to help people stay stopped’

22. So what we know is… Sustained recovery ‘is the norm’
Recovery capital is a predictor of sustained recovery
Treatment plays a part
Strong evidence around 12-step linkage
Families, aftercare, communities important
Research for Recovery, Scottish Government (2010)

23. Recovery Part 2: staying there

24. Getting plugged in makes you well
Holt-Lunstad & colleagues (2010)
Grella & colleagues (2008)
Litt & colleagues (2009) 24

25. Litt et al – “Changing network support for drinking” (2009)
186 participants randomised to network support (NS) or case management (CM) or a combo
Network support condition resulted in better outcomes than case management or combo
“The addition of just one abstinent person to a social network increased the probability of abstinence for the next year by 27%” (p230)
Social networks can be changed by an intervention that is specifically designed to do so
Mark Litt and colleagues at the University of Connecticut recruited186 alcoholics and randomised them to network support (NS) or case management (CM) interventions
Network support condition resulted in better outcomes than case management
“The addition of just one abstinent person to a social network increased the probability of abstinence for the next year by 27%” (p230)
Social networks can be changed by an intervention that is specifically designed to do so
McKnight and Block (2010): Stronger support networks linked to better access to community resources and to better health 25

26. Where do we consistently find communities of recovering people?
1,200 groups weekly in Scotland

27. Growth of Cocaine Anonymous in Scotland

28. AA Literature Summary Hundreds of studies support benefits
Project match (12-step, MET, CBT)
Changes on par with professional Rx
Lower healthcare costs
Despite concerns, similar benefits for:
Women, young people, ethnic groups
Comorbid populations, non-religious
AA’s growing influence and purported success at facilitating long-term addiction recovery has garnered increasing public health and scientific scrutiny (Ferri, Amato, & Davoli, 2006; Institute of Medicine, 1990; McCrady & Miller, 1993). In terms of its verifiable impact, hundreds of published studies, many in top scientific journals, have supported the beneficial effects of AA in helping alleviate alcohol and other drug problems. This body of scientific literature has been summarized in narrative reviews as well as quantitatively, through rigorous meta-analyses (Emrick et al., 1993; Ferri et al.; Humphreys et al., 2004; Kaskutas, 2009; Kelly, 2003; Kownacki & Shadish, 1999; Tonigan et al., 1996; White, 2009). AA participation is associated with producing and maintaining salutary changes in alcohol and other drug use that are on par with professional interventions while simultaneously reducing reliance on professional services and thus lowering related health care costs (Humphreys & Moos, 2001; Humphreys & Moos, 2007; Humphreys et al.; Kelly & Yeterian, 2012). Despite some earlier concerns regarding AA’s ability to cater effectively to women, young people, people of color, those with comorbid psychiatric illnesses, and non-religious/spiritual persons, research has found that AA confers similar benefits to women as men (Del Boca & Mattson, 2001; Kelly, Stout, Zywiak, & Schneider, 2006); to young people (Alford, Koehler, & Leonard, 1991; Chi, Kaskutas, Sterling, Campbell, & Weisner, 2009; Kelly, Brown, Abrantes, Kahler, & Myers, 2008; Kelly, Dow, Yeterian, & Kahler, 2010; Kelly, Myers, & Brown, 2000; Kennedy & Minami, 1993); to many (e.g., Ouimette et al., 2001; Timko, Sutkowi, Cronkite, Makin-Byrd, & Moos, 2011), but not all, persons with psychiatric conditions (e.g., those with severe social impairments and/or psychotic spectrum illness; Bogenschutz & Akin, 2000; Kelly, McKellar, & Moos, 2003; Noordsy, Schwab, Fox, & Drake, 1996; Tomas- son & Vaglum, 1998); and to those individuals who are non-religious/spiritual or less religious/spiritual (Kelly et al., 2006; Winzelberg & Humphreys, 1999).
Kelly & White 2012

29. Change of identity
For many enduring recovery means forging a new identity*
Shifting from ‘addict’ identity to ‘recovering’ or ‘recovered’ identity
Moving out of culture of addiction to culture of recovery**
*McIntosh & McKeganey 2000; **White 1996

30. Avoiding relapse
Cues
Priming dose
Stress

31. Family
“The effects of brief professional interventions on long term recovery outcomes are more ephemeral than the more enduring roles of family and social support”
Moos 1994

32. Family People do better when families involved in treatment*
And in social network interventions**
Need to build more evidence as almost no research in UK on this
*Landau, 2004; Fischer 2008; **Copello 2005

33. Build recovery capital: Meaningful activity
Education
Employment
Volunteering
Routine

34. Mapping the recovery journeys of former drinkers in recovery Hibbert and Best (2011, Drug and Alcohol Review)

37. Dr David McCartney +44 131 456 0221 david. mccartney@nhslothian. scot
Dr David McCartney