The Varieties of Recovery Experience Recovery Oriented Systems of Care OETAS Fall 2009

Variability of Alcohol and Drug Problems  Continuum from non-use to regular heavy use  Diagnostic classifications  Substance Abuse and  Substance Dependence  Wider span of problematic use is not captured in diagnostic classifications

Chronic Disease?  NOT all alcohol and drug problems are chronic disorders  No inevitable progression from alcohol abuse to alcohol dependence  Sustained use without acceleration is common  Deceleration of alcohol and drug problems with age-related maturation is common

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

Community vs. Clinical Populations  Marked differences  Conclusions drawn from clinical populations are not necessarily true for community populations and vice versa

Clinical Populations  Greater personal vulnerability  Family history of substance use disorders  Child maltreatment  Early puberty  Early age of onset of AOD use  Personality disorders during early adolescence  Substance using peers  Greater cumulative lifetime adversity

Clinical Populations  Greater severity and intensity  Greater AOD related consequences  Higher rates of developmental trauma and posttraumatic stress disorder  Higher co-occurrence of other medical/psychiatric illness  Greater personal and environmental obstacles to recovery  Lower levels of recovery capital

Recovery Capital  People who achieved natural recovery had substantial recovery capital to achieve prolonged abstinence Strong social support network of sober friends and family Strong social support network of sober friends and family Well-paying jobs Well-paying jobs Education Education Range of coping skills Range of coping skills

 Natural recovery is the predominant pathway of resolution for transient substance-related problems and less severe substance use disorders  professionally directed treatment is the dominant pathway of entry into recovery from substance dependence Community vs. Clinical Populations

Moderated Resolution of AOD Problems  Sustained moderated recoveries can be achieved with less severe problems and greater personal resources  Recovery from severe substance dependence is achieved primarily through complete and sustained abstinence

Varieties of Recovery Experience  Full or partial  High or low bottom  Amount 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 Experience  Abstinence based  Moderation based  Medication assisted

The Context of Recovery Initiation  The context in which people achieve remission from substance use disorders varies considerably and includes styles of  solo recovery,  treatment-assisted recovery, and  peer assisted recovery.  Not mutually exclusive

Peer Assisted Recovery  Peer-assisted recovery involves the use of structured recovery mutual aid groups to initiate and/or maintain recovery from AOD problems.  Mutual aid involvement, as measured by studies of A.A., can play a significant role in the movement from addiction to recovery

Peer Assisted Recovery  This positive effect extends to:  adolescents  women and cultural minorities  persons experiencing substance use and psychiatric disorders  persons using medications to support their recovery and  agnostics and atheists

Dose Effect The probability of stable remission rises with: The probability of stable remission rises with:  the number of meetings attended in the first three years of recovery  the intensity of involvement

Recovery Support Services  Peer-assisted recovery is also reflected in  the growing recovery home movement (most visibly in the Oxford Houses) and  the rapid growth of non-clinical, peer-based recovery support services.

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

Acute Care Model  Viability varies across clinical settings  For high functioning populations presenting with low to moderate problem severity and high recovery capital, AC model may work because client’s own internal and external assets sustain the transition from recovery initiation to recovery maintenance

 NOT all persons with AOD problems need specialized, professional, long- term monitoring and support  Many recover on their own and/or with family or peer support; again, research is needed to identify who is most likely to need intensive professional care.

 Among those who do need treatment, relapse is NOT inevitable.  NOT all persons suffering from substance dependence require multiple treatments before they achieve stable, long-term recovery.

 Even with those who do relapse following treatment, families, friends, and employers should NOT abandon hope for recovery.  Community studies of recovery from alcohol dependence report long-term recovery rates approaching or exceeding 50%.

 Having the serious chronic illness of addiction DOES NOT reduce personal responsibility for continuous efforts to manage that illness – just as those with serious diabetes or hypertensive disease must also manage their illnesses.  Current addiction treatment outcomes are NOT acceptable simply because they are compatible to those achieved with other chronic disorders.

 Appropriate treatment for chronic addiction is NOT simply a succession of short-term detoxifications or treatment stays.  Appropriate continuing care requires personal commitment to long-term change, dedication to self-management, and community and family support and monitoring.

As the field evolves,  Broader service philosophy and service menu for those with less severe AOD problems  Development of models that allow addiction treatment programs to manage the long term course of recovery from severe AOD dependence

References   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