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Laudet ROSC_ATTC Tampa july 2010 talk IN IRETA BLUE

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Laudet ROSC_ATTC Tampa july 2010 talk IN IRETA BLUE Powered By Docstoc
					   ADDICTION RECOVERY
Where are we going? How do we get there?

 Lessons from the recovery experience for service development

                 Alexandre B. Laudet, Ph.D
     Institute for Research, Education, and Training in Addictions




                      Tampa, FL ● August 2-4, 2010
       ACT ONE
WHY ARE WE HERE TODAY?
Why are we here today?
  For many, substance use disorders are chronic (on par with diabetes, asthma etc…)
      Addiction can not be cured but it can be arrested or managed
      For some, it may require ongoing care of various intensities over time (e.g.,
      intensive services, stepped down or after care, recovery checkups, 12-step)


HOW ARE WE TREATING ADDICTION?
      Acute model of care (assess, treat, discharge)
      Focused on symptoms, not on promoting wellness
      Short-term episodes of intensive care are ill-suited to manage a chronic
      condition:
            High attrition rate - e.g., 60% attrition from outpatient nationwide
            Few achieve abstinence during treatment
            High relapse rates after treatment –50– 60% within 6 months following
            treatment
            Costly cycling through multiple episodes of care – e.g. in one study in
            NYC, 80% outpatient client report 1 or + previous episode, 50% >3
            People don‟t get better, some die, families and communities suffer
A wind of change…
 Recovery is more than abstinence from alcohol and
   drugs; it is about building a full and productive life in
   the community. Our treatment systems must
   reflect and help people achieve this broader
   understanding of recovery. (Dr. W. Clark, 2007)




   Recovery Oriented System of Care (ROSC)
Elements of Recovery-Oriented Systems
of Care
 A ROSC is a coordinated network of community-based services and supports that is
 person-centered and builds on the strengths and resilience of individuals, families,
 and communities to achieve abstinence and improved health, wellness, and quality of
 life for those with or at risk of alcohol and drug problems.

  Person-centered
  Family and other ally involvement
  Individualized and comprehensive services
  Systems anchored in the community
  Continuity of care
  Partnerships
  Strength-based
  Culturally responsive
  Responsive to personal belief systems
  Commitment to peer services
  Include recovering people and families
  Integrated services
  System-wide educational and training
  Ongoing monitoring and outreach
  Outcomes-driven
   Evidence-based
  Adequately and flexibly funded
                                                     From W. Clark, CSAT, Generic ROSC talk
Paradigmatic shifts needed to implement ROSC



      From intense episodes of acute specialty care to
      multi-systems, person-centered continuum of
      care

      From addressing pathology to promoting global
      health, wellness, and recovery
Recovery Oriented System of Care

  THIS SOUNDS VERY GOOD
  THIS MEANS BIG CHANGES (more PAPERWORK???)
  HOW DO WE GET THERE?
     NEED TO KNOW
     1. What recovery means
     2. What helps/hinders the process
     3. How this can be translated into services and policy
          At the patient level
          At the program level
          At the system level
How much do we know about recovery?

 Research has mirrored the service delivery paradigm
     Focused on primary symptom as outcome
     Focused on treatment populations
     Short term studies mostly


 As a result, we lack information on:


     What „recovery‟ means: abstinence + WHAT?
     Long-term recovery paths, patterns and their predictors
     Especially among persons who are not enrolled in treatment
How can we promote/support an outcome we have not
         examined and poorly understand?
We need a science of recovery
 to inform Recovery Oriented
        Systems of Care
What will the science of recovery do?

  Support the development, monitoring and evaluation of
    ROSC at all 3 levels by answering:

  1. Destination: Where are we going? Specifically what are
    we trying to promote (what is recovery? long-term recovery)?



  2. Roadmap: How do we get there? What to put in our
    recovery-oriented services toolbox to best serve clients as their
    needs change?

  3. Are we there yet? How can we measure recovery
    outcomes? (for service monitoring and quality improvement,
    accountability)
  Summary of key datasets
 used in today’s presentation

NIDA funded studies conducted in NYC 2002 - 2009
Pathways: The community-based sample
  Study funded to elucidate patterns and psychosocial predictors of stable
  abstinence from drugs and alcohol use

  Media recruited sample (N = 354) re-interviewed yearly 3 times: one-, two-
  and three year follow-up (83% retention of surviving BL cohort of 342)

  Self-reported abstinence at baseline from one month to 10+ years

  Primarily members of inner-city ethnic, underserved minorities

  Long & severe history of (primarily) crack and/or heroin use

  Almost all are polysubstance users

  30% HepC+ and 22% HIV+

  Almost all have used formal addiction treatment services and 12-step
  fellowships
Pathways participants were classified by baseline
abstinence duration according to clinically
meaningful stages



              Three+ yrs   < 6 mos. Drug
                 27%         abstinent
                                27%




           18 to 36 mo.
               20%         6 to 18 mos.
                                26%
Twelve-step as aftercare: The outpatient
treatment sample
 Study funded to identify predictors, patterns and outcomes of 12 step
 participation after outpatient


 Recruited consecutive admissions at two publicly funded outpatient
 programs
 250 clients re-interviewed at treatment end (90% re-contact) who constitute
 the prospective study cohort
 Follow-up interviews 3-, 6- and 12-months post treatment end
 Full dataset on 219 participants ( 87.6% retention) one year post discharge
 Primarily members of inner-city ethnic, underserved minorities

 Long & severe history of (primarily) crack and/or heroin use

 Average of 5.8 previous treatment episodes
       ACT TWO
WHERE DO WE NEED TO GO?
       Recovery
Substance users try to quit because they want a
better life
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” (N = 354)

           Didn't like where life was
                                                                                  94%
          going/feared consequences

                  Desire for a better life                                   93


                   Tired of the drug life                                    92


      Didn't like what I was becoming                                       90

              Weighing pros & cons of
                                                                       86
                  continued use
      Negative effects of drug use on
                                                                     83
                  others

Laudet & White, 2004a                        50                75                 100
Does quitting use ‘lead’ to a better
              life???
    Benefits of recovery: Open-endeda
    What, if anything, is/would be good about being in recovery?
    RECOVERY = A BETTER LIFE



                           ch ance                                                         33%
             New life/2nd                                                       23
                       Clear head
                              ment                                              23
                Self-improve
                                                                          18
                        tion/goals
           Having direc                                                  17
                                    e
                    Better attitud
                                                                       16
                       conditions
         Better living                                                 16
                           l health
    Better physical/menta                                        13
                                 life
                  Better family
                                  ds                        11
                   Having frien


                                        0    5         10         15       20    25   30    35

a   Add to > 100% because up to 3 answers were coded
     Stress and Quality of Life Satisfaction as a
      Function of abstinence duration (N = 354)

                                   8.5
    Mean (scale range = 0 to 10)




                                   8.0



                                   7.5



                                   7.0



                                   6.5



                                   6.0
                                                                               Overall life
                                   5.5                                         satisfaction

                                   5.0                                         Stress rating pst yr
   >6 months                                             18 to 36 mos
                                         Six to 18 mos                  3+ years

                                            RECOVERY STAGE

Laudet, Morgen & White, Alc. Tx Q. 2006
Recovery definitions
Recovery definitions

   Recovery from alcohol and drug problems is a process of change
   through which an individual achieves abstinence, improved
   health, wellness, and quality of life. (CSAT, 2005 National
   Recovery Summit)



   Recovery from substance dependence is a voluntarily maintained
   lifestyle characterized by sobriety, personal health, and
   citizenship. (Betty Ford Institute, 2007)
     Let‟s ask the REAL experts…
          People in recovery!



    Let’s ask the REAL
experts…people in recovery!
Recovery definition: Open-endeda
How would you define "recovery from drug and alcohol use"?

RECOVERY GOES BEYOND SUBSTANCE USE




Better life/new life                                                             44%


     Total abstinence                                                       41%

  Lifelong process                                    21%

                                              17%
 Dealing w/issues

                        0              10             20              30    40         50



 a   Add to > 100% because up to 3 answers were coded; Laudet, JSAT, 2007
  My definition of recovery is life… „Cause I
 didn‟t have no life before I got into recovery



                Pathways study participant H.W. 42 years old Af-Am male




Laudet, JSAT, 2007
Recovery is a process, not an endpoint
“Recovery is a continuous process that never ends”




                                                          96.8%
  Agree/Strongly
      agree

Disagree/Strongly         3.2%
    disagree

                      0      20    40       60       80           100


 Laudet, JSAT, 2007
         Relevance to ROSC

           Recovery is a reality

Recovery is a Process of Change and Growth
Recovery is Sobriety + improved quality of life
Destination Recovery:
  Few Direct flights
  FOR TOO MANY PEOPLE,
  ADDICTION IS A CHRONIC
  RELAPSING CONDITION…

That’s where ROSC comes in…
Addiction career Number of abstinent periods one month
or longer followed by return to drug use prior to current abstinence*
                  50% reported 4 or more abstinent periods
                    followed by return to active addiction


                                     One                         20 & over
                                     17%                            10%

                                                                                   Ten to 19
                                                                                     17%

                        Two
                        22%                                                        Six to nine
                                                                                       7%

                                      Three                           Four to five
                                       11%                               16%




*Outside of controlled environment, among those who report one or more such periods: 71% N=248
Laudet & White 2004b
  Relevance to ROSC

Continuity of services and supports
            ACT THREE
What’s wrong with the current model?
NYC Outpatient treatment outcome



                                                   Completed
                                                     40%
      Left before
      completion
         60%


Completion rate on par w/ national average of 36% for outpatient modalities



 Laudet, Stanick, & Sands, JSAT 2009
% Returned to substance use in the post-treatment
year as a function of discharge status
Drop-outs were 2.8 times more likely to return to drug use in the year after
services ended than were treatment completers (95%CI =1.86-4.23, p>.001)


        100

         90
         80                      92.6%
         70
         60

         50      57.8%
         40
         30

         20

         10
          0
              Completed Left before
                                                            Chi. Sq. 35.5, p = .0000
                        completion                          Stanick, Laudet & Sands, 2008
Treatment Career: Number of prior episodes
                 Over half of outpatient clients have had
                      3 or more previous episodes



                                Ten +            None
                                 14%             21%

        Five to nine
            21%

                                                        One
                                                        15%

                           Three-four         Two
                              17%             12%




Laudet, Stanick & Sands, Eval Review, 2007
One third seek treatment again in the 12
months after leaving the index episode


                                        Additional treatment
                        No additional           31%
                         treatment
                            69%




 Laudet and Stanick, CPDD 2010
Reasons for leaving treatment: Qualitative analyses
What is the most important reason why you dropped out of the program?*

         Dislike
                                                         31.6%
   program/staff/clients
  Tx interferes w/other
                                             18.8
    activity (e.g., job)

                  Using                 12

     Convenience (e.g.,
                                        12
        transport)

Family/personal issues                  12

       Do not want help                 12

              Finances            9.4

             Not helpful         8.5

                           0        5          10         15        20         25         30          35


* Add to > 100% because up to 2 answers were coded; Laudet, Stanick, & Sands, JSAT 2009, 37:182-190
Minimizing attrition [1]

Is there anything the program could have done differently so that you
    would have continued attending?




                                                           No
                                                          67%

              Yes
              33%




Laudet, Stanick, & Sands, JSAT 2009
Minimizing attrition [2]
What could have been done differently so that you would have continued
  attending (among ‘yes’)




                                          Practical
              Greater flexibility
                                         assistance
                in scheduling
                                            11%       Help with other
                     23%
                                                         areas of
                                                       functioning
                                                           18%



                 Better
             individualized
                                            Better, more
                services
                                            caring staff
                  23%
                                                25%




Laudet, Stanick, & Sands, JSAT 2009
 Substance use is but a symptom,
Promoting abstinence is not enough
Expectation of help
Overall, how much do you think your coming to this treatment
program will help you address your needs and priorities?


                             Not at all   A little
                                1%          4%


                                               Quite a bit
                                                  24%

                 Very much
                    71%
Remember this? 33% of drop outs may have stayed longer if
they had help in other life areas …   Missed opportunities?
What could have been done differently so that you would have continued
  attending (among ‘yes’)




                                              Practical
                Greater flexibility
                                             assistance
                  in scheduling
                                                11%       Help with other
                       23%
                                                             areas of
                                                           functioning
                                                               18%



                  Better/more
                  caring staff                        Better
                      25%                         individualized
                                                     services
                                                       23%

Laudet, Stanick, & Sands, JSAT 2009
Quality of life satisfaction
 sustains abstinence…
Quality of life satisfaction predicts sustained
abstinence: Community based sample
                                      Want that           Pass on Donut
    DIET          Jeans fit better
                                       feeling

                                           Want to                 SAY NO
  Stop                    HAPPIER         stay happy              TO DRUGS
  drugs




 Controlling for other relevant variables, baseline QOL satisfaction predicts
               sustained abstinence one and two years later.
         Association partially mediated by motivation for abstinence




Laudet, Becker & White, 2009, 44
“What worked for me is just the thought that I don‟t wanna
 go through that madness no more. … See, „cause if I was
      to use again, I probably would lose everything”.

                      Pathways participant




        Behavioral economics: Demand law
But what makes them happy???
Priorities @ outpatient admission
What are the priorities in your life right now? (N = 314)



    Get/Stay clean

          Get a job

 Educ/Voc/Training

     Get kids back
                                           Abstinence is top goal
           Housing
                                            but not only goal!!!
  Relation w.family

   Get life together

       Complete tx

                       0   10       20         30           40      50
Life priorities in recovery by abstinence duration
“What are the priorities your life right now?”   (N = 354)

             Recovery

         Employment

        Relationships
                                                             < 6 mos.
        Educ/training                                        6 - 18 mos.
           Normal life                                       18 - 36 mos.
                                                             > 3 years
Family reunification

               Housing

                            0   10   20    30          40      50          60
Laudet & White, JSAT 2009
           Relevance to ROSC


Individualized and comprehensive services/supports

         Multi-system Integrated services
              ACT FOUR
With a little help from my friends…
Sources of support in long-term recovery
Pathways pilot (N = 52 CCAR members, median abstinence duration 12 yrs)


                                                                              53%
                          ith
             ua   lity/fa
     S pirit                                                                 53
                       ily
                   Fam
                                                                   43
                          s
               g     peer
         overin
   Rec                se
                                                    18
               S pou
                                                   17
                    gth
             rs tren
       /inne
  Self
                                              11
                     ds
               F rien
                                     7
                      ns
            Cli nicia
                                0        10         20   30   40        50          60



Laudet, Savage & Mahmood, J. Psychoactive Drugs, 2002
Lessons learned from Relapse                                                        a

                                Top answers (<10%)
       What if anything have you learned from the relapse experience?



                                                 it...                              21.8%
                                     e it  prior
                         very  /mak
                nt reco                            b ad                      18.7
       Must wa                         /dru gs =
                           n=   good
                      Clea                          ers                      18.3
                                             trigg
                                      from
                           t/a void
                   n abo u                          ort               15.1
            Lear                             sup p
                                        o ut
                           co v   er w/
                      ot re                                    11.5
               Ca nn                       ress
                                                  fe...
                                        xp
                                 ues/e
                          s iss
                 ad  dres                            lly      10.3
       Ne ed to                         u se s ocia
                              t/ can't
                     n addic
              I'm a

a
    Among those who report one or more such periods: N=253; Laudet & White, 2004b
Strategies to deal with relapse triggers:
Most cited = Seek support, stay focused on recovery
                               Distraction
                                   6%                          Meditate/pray
                                                                    8%



            Seek help/support,
              Talk about pb
                   44%
                                      Stay focused
                                          42%




C
    Among those who report a challenge; Laudet & White 2004b
Example of source of support and motivation:
         Twelve-step fellowships
Role of continuous 12-step attendance on odds of
abstinence sustained for two years: Pathways study



                                      8
                      8
                          6.25
                                               5.7
                                                        4.5
                                                                  4.5
                      4




                      0
                           Total   Under 6 Six to 18 18 to 36    Three
                          sample   months months months         years +
Laudet & White 2006
         Relevance to ROSC

 Draw on Support from peers, family
members, significant others, friends,
      and the community
                 ACT FIVE
                So what???
Translating Research into Recovery Oriented Systems
Recovery Oriented System of Care makes
Sense…

   Based on the experience of people in treatment and in recovery, the
   core elements of ROSC „make sense‟

   The transition to ROSC will
      Take time
      Take full commitment from the „system‟ including payors
      Take place gradually

   Experience and success of „leader states/cities‟ (e.g., CT, Philly, ) will
   be invaluable

   In the meantime, strive to ADOPT AS MANY ELEMENTS OF ROSC AS
   BUDGET ALLOWS
Recovery Oriented System of Care makes Cents…
   Mathematical simulation of the costs of methadone treatment over the lifetime
 for an opiate dependent individual under the chronic vs. acute model of care:
 „We find that the benefit-cost ratio of treatment from our lifetime model (37.72)
 exceeds the benefit-cost ratio from a static model (4.86)’ (Zarkin et al., 2005, p.
 1133).

                                    NOT CONVINCED YET???

 The Connecticut experience* (statewide ROSC)

   24% decrease in expenses
   46% increase in number of people served statewide
   62% decrease of acute care
   40% increase in outpatient care
   25% decrease in annual cost per client
   14% lower cost with recovery support



 * 2008 statewide data from Kirk, in press in Kelly and White
                                                                                   60
Let’s get to work!
      Questions? Comments?
        How can we help?




http://www.attcnetwork.org/regcenters/index_northeast.asp
                      www.ireta.org
           Email: alexandrelaudet@gmail.com

				
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