1. 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 Recovery National Development and Research Institutes, Inc. Correspondence: laudet@ndri.org laudet@ndri.org

2. 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

4. 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

5. 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

6. 6 Why study the recovery process ?

7. 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)

8. Why study the recovery process ? [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.

9. 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

10. 10 “One of the great surprises of longitudinal research is that you discover that people do recover” George Vaillant

11. 11 What does ‘Recovery’ mean?

12. 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

13. Pathways Participants Recovery definition

14. 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

15. Recovery patterns Few long-term studies on recovery (<2 yrs) 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)

16. 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

18. Pathways to Long-Term Abstinence Relapse History (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?

19. Relapse History Number of clean periods followed by return to active addiction b Over 50% reported 4 or more abstinent periods followed by return to active addiction Range 1 to 90 Mean = 7.56; Std dev= 10.6 b Among those who report one or more such periods: N=248- 5 “don’t know”

20. Length of longest ‘clean’ period before return to active addiction Length of longest ‘clean’ period before return to active addiction b 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 periods: N=253

21. Length of relapse after longest clean period 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 such periods: N=253

22. 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

23. Relapse after Recovery b What got you back to using? Top answers (<10%) B Among those who report one or more such periods: N=253

24. Relapse after longest clean period b Lessons learnt Top answers (<10%) B Among those who report one or more such periods: N=253

25. Strategies to deal with recovery challenges Pathways participants c Seeking support and staying focused C Among those who report a challenge

26. 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

27. 27 Recovery Capital

28. 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

29. 29 Recovery Capital Cognitive recovery readiness

30. 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 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. identifying with others in recovery. Increasing/higher levels of these cognitive processes found to be associated with better subsequent substance use outcomes.

31. Cognitive Recovery Readiness across Stages of Change

32. Cognitive Recovery Readiness as a function of help seeking career Prior treatment here – same trend with prior 12-step attendance

33. So, Cognitive recovery readiness… Increases over stages of change Increases as a function of cumulative recovery help seeking (treatment and 12-step)

34. 34 Recovery Capital 12-step fellowships

35. 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.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 useParticipation 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 effectsConcurrent use of 12-step and formal treatment has been shown to have additive effects

36. 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. 38 12-step attendance: Patterns and attrition

39. 12-step Attendance patterns Aftercare 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. 41 Perceived helpfulness and benefits of 12-step groups

42. Attitudes about 12-step among Drug Treatment patients Attitudes about 12-step among Drug Treatment patients e e Scale range from 0 to 10

43. Reasons for 12-step attendance f,g F among ‘ever’ attenders; g Add to < 100% because 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. 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 < 100% because up to 3 answers were coded

47. Observation… Reasons cited for not attending 12-step groups mirror the lessons learnt from relapse and helpful strategies to recover: Don’t 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

48. 48 Recovery Capital Spirituality, Faith and Life meaning

49. Baseline Spirituality, Religiosity, Life meaning and Recovery @ F1

50. Pathways Pilot Spirituality and religion as Recovery support (N=52) 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 recovery h

51. Pathways to Long-Term Abstinence Sources of strength and support in recovery a

52. So, spirituality/religion… Cited as critical source of recovery support Associated with sustained recovery over time

53. 53 Why do substance users seek recovery?

54. Pathways to Long-Term Abstinence Factors 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.”

55. 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?

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

57. 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 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…

58. Recovery capital: Buffering Stress and Enhancing Quality of Life in recovery j ( N = 354) Stress Spirituality17% General Social suprt9.6% Length of recovery9.1% Religiousness8.5% Recovery support7.3% Life meaning5.6% 12-step involvement3.5% 12-step attendance0 Quality of life j j All betas p<.001 except 12-step attendance RECOVERY CAPITAL ACCOUNTS FOR 60.6% OF VARIANCE IN QOL

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 @ F1: Lifetime severity Length of recovery @ 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

60. Predictors of sustained recovery @ F1: Total sample and baseline recovery stages N = 287 Predictors of sustained recovery appear to differ across recovery stages… Total> 6 months6 to 18 mos.18 to 36 mos. 3 yrs + % variance explained15%23%32%12%15% Lifetime severityxxnsxns Length of recovery @ basexxxnsns Commitment to abstinencensnsxnsx Embracement disease modelnsxnsnsns 12-step attendance pst yrnsxnsnsns Recovery supportnsxnsnsns Religiositynsnsnsxx Life meaningx nsnsnsx

61. 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

62. 62 Recovery revisited… Beyond drug use & abstinence

63. 63 “If you want to treat an illness that has no easy cure, first of all, treat them with hope” George Vaillant

64. Recovery definition revisited Pathways participants g How would you define "recovery from drug and alcohol use"? Please be as specific as you can. [RECORD VERBATIM] RECOVERY GOES BEYOND SUBSTANCE USE G Add to < 100% because up to 3 answers were coded

65. Positive aspects of recovery Pathways participants g G Add to < 100% because up to 3 answers were coded

66. 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’ Preliminary evidence indicates that different factors are critical to recovery at different ‘stages’

67. 67 Looking forward… MEASUREMENT and RESEARCH ISSUES

68. 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? 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)?

69. 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)

70. 70 We’ve only just begun… Where do we go from here? Where do we go from here?

71. Toward a Recovery-Oriented Research Agenda 1. Use a telescope, not a microscope (George Vaillant) 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

72. 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: 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