The Varieties of The Varieties of Recovery Recovery ExperienceExperience

Recovery Oriented Systems of CareRecovery Oriented Systems of Care

OETAS Fall 2009OETAS Fall 2009

Variability of Alcohol and Variability of Alcohol and Drug ProblemsDrug Problems Continuum from non-use to regular Continuum from non-use to regular

heavy useheavy use

Diagnostic classifications Diagnostic classifications Substance Abuse and Substance Abuse and Substance DependenceSubstance Dependence

Wider span of problematic use is not Wider span of problematic use is not captured in diagnostic classificationscaptured in diagnostic classifications

Chronic Disease?Chronic Disease? NOT all alcohol and drug problems are NOT all alcohol and drug problems are

chronic disorderschronic disorders No inevitable progression from alcohol No inevitable progression from alcohol

abuse to alcohol dependenceabuse to alcohol dependence Sustained use without acceleration is Sustained use without acceleration is

commoncommon Deceleration of alcohol and drug problems Deceleration of alcohol and drug problems

with age-related maturation is commonwith age-related maturation is common

Natural RecoveryNatural Recovery

When problems are of later onset and When problems are of later onset and lower severity, many persons resolve them lower severity, many persons resolve them on their own or through brief intervention on their own or through brief intervention outside specialized addiction treatmentoutside specialized addiction treatment Sustained abstinenceSustained abstinence Sustained moderated AOD useSustained moderated AOD use Continued sub-clinical problemsContinued sub-clinical problems Move between patternsMove between patterns

Community vs. Clinical Community vs. Clinical PopulationsPopulations

Marked differencesMarked differences

Conclusions drawn from clinical Conclusions drawn from clinical populations are not necessarily populations are not necessarily true for community populations true for community populations and vice versaand vice versa

Clinical PopulationsClinical Populations

Greater personal vulnerabilityGreater personal vulnerability Family history of substance use disordersFamily history of substance use disorders Child maltreatmentChild maltreatment Early pubertyEarly puberty Early age of onset of AOD useEarly age of onset of AOD use Personality disorders during early Personality disorders during early

adolescenceadolescence Substance using peersSubstance using peers Greater cumulative lifetime adversityGreater cumulative lifetime adversity

Clinical PopulationsClinical Populations

Greater severity and intensityGreater severity and intensity Greater AOD related consequencesGreater AOD related consequences Higher rates of developmental trauma and Higher rates of developmental trauma and

posttraumatic stress disorderposttraumatic stress disorder Higher co-occurrence of other Higher co-occurrence of other

medical/psychiatric illnessmedical/psychiatric illness Greater personal and environmental Greater personal and environmental

obstacles to recoveryobstacles to recovery Lower levels of recovery capitalLower levels of recovery capital

Recovery CapitalRecovery Capital People who achieved natural recovery had People who achieved natural recovery had

substantial recovery capital to achieve substantial recovery capital to achieve prolonged abstinenceprolonged abstinenceStrong social support network of sober Strong social support network of sober

friends and familyfriends and familyWell-paying jobsWell-paying jobsEducationEducationRange of coping skillsRange of coping skills

Natural recovery is the predominant Natural recovery is the predominant pathway of resolution for transient pathway of resolution for transient substance-related problems and less substance-related problems and less severe substance use disorderssevere substance use disorders

professionally directed treatment is the professionally directed treatment is the dominant pathway of entry into recovery dominant pathway of entry into recovery from substance dependencefrom substance dependence

Community vs. Clinical Community vs. Clinical PopulationsPopulations

Moderated Resolution of Moderated Resolution of AOD ProblemsAOD Problems

Sustained moderated recoveries can be Sustained moderated recoveries can be achieved with less severe problems and achieved with less severe problems and greater personal resourcesgreater personal resources

Recovery from severe substance Recovery from severe substance dependence is achieved primarily through dependence is achieved primarily through complete and sustained abstinencecomplete and sustained abstinence

Varieties of Recovery Varieties of Recovery Experience Experience

Full or partial Full or partial High or low bottom High or low bottom Amount of Recovery CapitalAmount of Recovery Capital Frameworks of recovery initiation (religious,

spiritual, secular) Temporal styles of recovery initiation

(transformative change, incremental change, drift)

Recovery identity (positive, neutral, negative)

Varieties of Recovery Varieties of Recovery ExperienceExperience

Abstinence basedAbstinence based

Moderation basedModeration based

Medication assistedMedication assisted

The Context of Recovery The Context of Recovery InitiationInitiation The context in which people achieve The context in which people achieve

remission from substance use disorders remission from substance use disorders varies considerably and includes styles of varies considerably and includes styles of solo recoverysolo recovery, , treatment-assisted recoverytreatment-assisted recovery, and , and peer assisted recoverypeer assisted recovery..

Not mutually exclusiveNot mutually exclusive

Peer Assisted RecoveryPeer Assisted Recovery

Peer-assisted recoveryPeer-assisted recovery involves the use involves the use of structured recovery mutual aid groups to of structured recovery mutual aid groups to initiate and/or maintain recovery from AOD initiate and/or maintain recovery from AOD problems. problems.

Mutual aid involvement, as measured by Mutual aid involvement, as measured by studies of A.A., can play a significant role in studies of A.A., can play a significant role in the movement from addiction to recovery the movement from addiction to recovery

Peer Assisted RecoveryPeer Assisted Recovery

This positive effect extends to:This positive effect extends to: adolescents adolescents women and cultural minorities women and cultural minorities persons experiencing substance use and persons experiencing substance use and

psychiatric disorders psychiatric disorders persons using medications to support their persons using medications to support their

recovery andrecovery and agnostics and atheistsagnostics and atheists

Dose EffectDose Effect

The probability of stable remission The probability of stable remission rises with:rises with: the number of meetings attended in the the number of meetings attended in the

first three years of recoveryfirst three years of recovery the intensity of involvementthe intensity of involvement

Recovery Support Recovery Support ServicesServices

Peer-assisted recovery is also reflected Peer-assisted recovery is also reflected inin the growing recovery home movement (most the growing recovery home movement (most

visibly in the Oxford Houses) and visibly in the Oxford Houses) and

the rapid growth of non-clinical, peer-based the rapid growth of non-clinical, peer-based recovery support services.recovery support services.

NOT all AOD problems are chronic – NOT all AOD problems are chronic – most do not have a prolonged or most do not have a prolonged or progressive course – but some do, progressive course – but some do, and research is needed to identify and research is needed to identify early signs of chronic progression.early signs of chronic progression.

Acute Care ModelAcute Care Model

Viability varies across clinical settingsViability varies across clinical settings

For high functioning populations For high functioning populations presenting with low to moderate problem presenting with low to moderate problem severity and high recovery capital, AC severity and high recovery capital, AC model may work because client’s own model may work because client’s own internal and external assets sustain the internal and external assets sustain the transition from recovery initiation to transition from recovery initiation to recovery maintenancerecovery maintenance

NOT all persons with AOD problems NOT all persons with AOD problems need specialized, professional, long-need specialized, professional, long-term monitoring and support term monitoring and support

Many recover on their own and/or with Many recover on their own and/or with family or peer support; again, research family or peer support; again, research is needed to identify who is most likely is needed to identify who is most likely to need intensive professional care.to need intensive professional care.

Among those who do need Among those who do need treatment, relapse is NOT treatment, relapse is NOT inevitable.inevitable.

NOT all persons suffering from NOT all persons suffering from substance dependence require substance dependence require multiple treatments before they multiple treatments before they achieve stable, long-term recovery.achieve stable, long-term recovery.

Even with those who do relapse Even with those who do relapse following treatment, families, friends, following treatment, families, friends, and employers should NOT abandon and employers should NOT abandon hope for recovery. hope for recovery.

Community studies of recovery from Community studies of recovery from alcohol dependence report long-term alcohol dependence report long-term recovery rates approaching or recovery rates approaching or exceeding 50%.exceeding 50%.

Having the serious chronic illness of Having the serious chronic illness of addiction DOES NOT reduce personal addiction DOES NOT reduce personal responsibility for continuous efforts to responsibility for continuous efforts to manage that illness – just as those with manage that illness – just as those with serious diabetes or hypertensive disease serious diabetes or hypertensive disease must also manage their illnesses. must also manage their illnesses.

Current addiction treatment outcomes are Current addiction treatment outcomes are NOT acceptable simply because they are NOT acceptable simply because they are compatible to those achieved with other compatible to those achieved with other chronic disorders.chronic disorders.

Appropriate treatment for chronic addiction Appropriate treatment for chronic addiction is NOT simply a succession of short-term is NOT simply a succession of short-term detoxifications or treatment stays. detoxifications or treatment stays.

Appropriate continuing care requires Appropriate continuing care requires personal commitment to long-term personal commitment to long-term change, dedication to self-management, change, dedication to self-management, and community and family support and and community and family support and monitoring.monitoring.

As the field evolves,As the field evolves,

Broader service philosophy and service Broader service philosophy and service menu for those with less severe AOD menu for those with less severe AOD problemsproblems

Development of models that allow Development of models that allow addiction treatment programs to manage addiction treatment programs to manage the long term course of recovery from the long term course of recovery from severe AOD dependencesevere AOD dependence

ReferencesReferences

The Varieties of Recovery Experience: A Primer for Addiction Treatment Professionals and Recovery Advocates. William White, MA and Ernest Kurtz, PhD Chicago, IL

Recovery Management and Recovery-Oriented Systems of Care: Scientific Rationale and Promising Practices. William L. White, MA. Senior Research Consultant, Chestnut Health Systems