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

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

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Do people get better?

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, 1868-2011.)

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, 1868-2011.) White 2012

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

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)

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

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

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

Do people get better? Yes!

How does it happen?

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

Building Recovery capital 15

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

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

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

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

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’

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)

Recovery Part 2: staying there

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

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

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

Growth of Cocaine Anonymous in Scotland

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

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

Avoiding relapse Cues Priming dose Stress

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

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

Build recovery capital: Meaningful activity Education Employment Volunteering Routine

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

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