THE ROLE OF RECOVERED DRUG USERS THROUGHOUT THE TREATMENT CONTINUUM

Prof. Dr. Wouter Vanderplasschen

Ghent University, Dept. Of Orthopedagogy

Wouter.Vanderplasschen@UGent.be

Scope of this presentation Plenty of anecdotal and clinical evidence that recovered

users make a difference in alcohol and drug prevention & treatment AA, NA, CO Drug-free therapeutic communities Life stories - prevention Role models, social learning, peer support, mutual help, …

Only few A & D services make use of recovered users Underutilisation of the strong potential of recovered users in

alcohol & drug treatment services

How can we do better?

HOW DO PEOPLE RECOVER FROM ALCOHOL

AND DRUG ADDICTION?

1. Addiction, a shifting focus Addiction is diagnosed as an individual problem with various social

implications (American Psychiatric Association, 1994; Hser & Anglin, 2010), including a negative impact on public health, social cohesion and employement rates (McLellan e.a., 2000).

For a long time, a clinical approach of the concept 'dependence' was dominant: Dependence as an acute condition, where short, intensive,

symptom-oriented treatment should aim at achieving an abstinent lifestyle (Laudet & White, 2010).

Recovery as a set status, which requires abstinence. Abstinence as THE way to cure from addiction.

Recently, addiction is more and more seen as a chronic, relapsing brain disease (Van den Brink, 2005). Within addiction treatment the focus shifted from ‘cure’ to

controland stabilizing the problem (Hser & Anglin, 2010; McLellan, 2002; Van den Brink, 2005; White, 2004; White, 2007b).

Changing perspectives on ‘addiction’ (Van den Brink, 2005)

1750 - now

Moral model Prison, boot camps

1850 - now

Farmacological model

Ban on alcohol & drugs

1930 - now

Symptomatic model Psychotherapy

1940 - 1960

Disease model Medication; AA

1960 - 1970

Behaviourist model Behavioral therapy

1970 - now

Biopsychosocial model

Multi-modal therapy

1990 - now

Brain disease model Medical & psychosocial Tx

Addiction, a shifting focus (Van den Brink, 2005)

Brain imaging studies have shown that addiction is a brain disease inborn vulnerability as basis for misuse of

substances ~ repeated use of substances leads to changes in the brain

Craving is central in uncontrolled use and relapse during periods of abstinence.

Addiction chronic and relapsing disorder, of which recovery is possible

2. Treatment and prevention: intervening at the right moment

universeel

Preventie

selectief

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identificatievr

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ande

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stand

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beh

ande

ling

lange termijn behandeling

nazorg / zorggerichte preventie

Hulpverlening

Voortgezette zorg

Interventiespectrum voor psychische stoornissen (naar Mrazek en Haggerty, 1994)

Vroeginterventie

Universal, selective and indicated prevention

Universal

Selective

Indicated

Three types of prevention – Mrazek & Haggerty

Universal – the whole group Selective – vulnerable groups

Indicated – vulnerable individuals

Prevention: filteringSkill training in schools (e.g. Unplugged)

Adapted interventions for at

risk groups

Coping with impulsivity

Risk of stigmatisatio

n

Treatment

Outpatient drug-free Tx Substitution Tx Harm reduction services

Detoxification Residential rehabilitation Aftercare – continuing care

Have we evaluated addiction treatment correctly?! (McLellan, 2002)

- Low compliance and high relapse rates among addicted individuals !?- Less than 50% takes medication according to scheme- Less than 30% follows behavioural guidelines(diet, …)- 40-60% re-hospitalisation …- Usually no remission after 1st treatment

Still, not always chronical: Recovery is possible, even without Tx Long remission phase

Many persons do relapse, permanent vulnerabilty

Was Tx successul in this case?

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Pre T1 T2 T3 Post

X1Ernst problemen

Verloop behandeling

Course of medical Tx: hypertension, diabetes, …

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Pre T1 T2 T3 Post

X1Ernst problemen

Verloop behandeling

Course of substance abuse treatment?

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Pre T1 T2 T3 Post

X1

Ernst problemen

Verloop behandeling

HAVE PREVENTION AND TREATMENT

FAILED?

Have prevention and treatment failed?

No, but we should be realistic (not pessismistic) about our expectations and Tx outcomesStrong correlation between Tx dosage/length and outcomesSelection processes: motivation, right moment, …<3% abstinent after years of substitution TxTransgenerational cycles of addiction and deprivationCosts < benefits in terms of crime reduction, economic

participation, …Therapeutic alliance! Identification with counsellorParticipation in AA – aftercare can enhance Tx outcomesNeed for continuing formal and informal supportNeed for a recovery-approach

https://www.youtube.com/watch?v=bOMHz2-cGAQ (“20-2’20”)

THE RECOVERY MOVEMENT

Addiction recovery Recovery is increasingly studied in mental health research

and can be defined as: “The establishment of a fulfilling, meaningful life and a positive sense of

identity founded on hopefulness and self-determination” (Slade, 2010, p2.)

Recently, there is more attention for recovery in addiction research.

However, no real consensus on the interpretation of the term (McIntosh & McKeganey, 2000; Maddux & Desmond,1986):

Characteristics of recovery: Recovery as a dynamic concept

○ Addiction characterized as a chronic relapsing condition○ Substance users cycle between abstinence / period of less frequent

use and relapses into active drug use (Dennis, Scott, Funk, & Foss, 2005).

○ Recovery is a process rather than an event (Best, 2012)

Addiction recovery Recovery ≠ abstinence (Laudet, 2008; Fiorentine & Hillhouse,

2001)○ Recovery is a proces of personal growth, which is not limited

to substance use ○ Along problems regarding substance use, individuals

experience serious health, social and economic consequences (McLellan, Lewis, O’Brien, & Kleber, 2000)

○ Abstinence cannot be seen as THE defining element of recovery, but as one of the many ways to get to recovery (White, 2007).

○ Recovery without abstinence is possible! recovery does not stop with symptom-reduction, the individual process of growth can still be going Recovery is about achieving a contributing and satisfying life

Dimensions of recovery

Clinical recovery; based on the invariant importance of symptomatology, social functioning, relapse prevention and risk management. The focus is on achieving an abstinent life style (Slade, 2010; White, 2007; Van der Stel, 2012)

Functional recovery; focuses on the physical, psychological and social functioning of the individual.

Community recovery; focuses on the social position of the addicted individual and the prevailing stigma. The improvement of rights and the voice of addicted individuals is important.

Personal recovery; the lived experiences of individuals in recovery and it reflects the individually defined and experienced nature of recovery. Confidence, hope, motivation for change, … are seen as strengths which can lead to change. (Bradstreet, 2013; Leamy e.a., 2011; Vanderplasschen e.a., 2013)

The focus has mostly been on clinical recovery (Slade, 2010; The Betty Ford Institute Consensus Panel (2007)

However, personal recovery appears to be the driving force for understanding and realizing other types of recovery (GGZ Nederland, 2013; Van der Stel, 2012).

Recovery capitalRecovery has many pathways:

○ Recovery seen as an individual and personal journey, with a unique path and duration for every person in recovery (Best, 2012)

○ Initiating ~ sustaining recovery ○ Recovery needs support of other people, is a social process○ Recovery capital is crucial at different stages of the

recovery continuum (Best e.a., 2010; Laudet & White, 2008; Best & Laudet, 2010). Personal recovery capital: personal characteristics and skills which

can be supportive for recovery, such as specific competences, severity of dependence and style of attribution.

Social recovery capital: includes the social network of the individual and the extent to which the individual experiences support and acceptance from this network.

Community recovery capital: concerns the extent of support that is available within the wider community, such as housing, employment, training, treatment and self-help groups.

(Leamy, Bird, Le Boutillier, Williams & Slade, 2011)

How to exploit recovery capital (Best,

2012)? Process of recovery

Recovery does not necessary involve treatment:○ Natural recovery is possible

Great influence of social context Importance of choice and self-determination Personal and social resources (= recovery capital)

However, recovery and treatment should not be seen as alternatives, they are compatible

Treatment should include:○ Active engagement with local communities○ Links to those who can convey hope and belief that recovery is possible

Recovery is social○ It does not happen in isolation○ Significant effect of family members and friends on chance of relapse○ ‘assertive linkage’ to groups in active recovery Demonstration that

recovery is possible, by individuals further along the road of recovery is important

Towards recovery-oriented systems of care (Best, 2012) A noticeable growth towards recovery-thinking in the

field of addiction (policy and practice) is seen in the US and the UK.

The Barnsley ‘case’:○ Recruiting ‘recovery champions’

Strategic: managers to clarify the vision and model Therapeutic: changing practices, attitudes and belief Community: people in recovery, family members and others from the

local community who need to motivate and inspire recovery activity

○ Engagement of ‘emerging recovery champions’ Raising awareness in all key stakeholders Creating a recovery coalition Establishing a vision for recovery Attempting to communicate that vision

HOW TO ENGAGE RECOVERED INDIVIDUALS

THROUGHOUT THE TREATMENT CONTINUUM

Scientific evidence on ex-addicts & treatment

A lot of potential that is not used! Abundant evidence that involvement of recovered

users is of surplus value Change is needed towards a recovery approach

We need to do more than providing substitute drugs!Treatment is not enough to recover, ongoing support is

needed to deal with the challenges associated with this chronic disorder

Not only about individuals, but about their surroundings and communities who also suffered from addiction problems

We need to support addicted individuals’ to realized Connections, Hope, Identity, Meaning and Empowerment in their lives: RECOVERY!

Development of a recovery movement in Belgium. Why?

To raise awareness that recovery is possible! Sensibilistation through media, community activities and

organisation of events

To recruit ‘recovery champions’ that can support peers in various stages of the addiction process

Prevention, treatment, but foremost in continuing care

To disconnect recovery and treatment, as there are many pathways to recovery

To advocate for substance users’ rights and social position

To link with international networks and similar organisations:RUN (Recovered Users Network)

Thank you for your attention?

Wouter.Vanderplasschen@UGent.be