Exploring the recovery process: Patterns, supports, challenges and future directions

11

Exploring the recovery process: Exploring the recovery process: Patterns, supports, challenges Patterns, supports, challenges

and future directionsand future directions

Alexandre B. LaudetAlexandre B. LaudetPresented at the Seminar Series of the Division of Epidemiology, Services Presented at the Seminar Series of the Division of Epidemiology, Services

and Prevention Research (DESPR)and Prevention Research (DESPR)

National Institute on Drug Abuse (NIDA)National Institute on Drug Abuse (NIDA)

April 20, 2005April 20, 2005

Center for the Study of Addiction and RecoveryCenter for the Study of Addiction and RecoveryNational Development and Research Institutes, Inc.National Development and Research Institutes, Inc.

Correspondence: Correspondence: [email protected]@ndri.org

In collaboration with…In collaboration with…

Co-Investigators: William L. White, Chestnut//LighthouseCo-Investigators: William L. White, Chestnut//Lighthouse

Gordon Storey, Gordon Storey, Self-Help Addiction Resource Self-Help Addiction Resource Center (SHARC)Center (SHARC)

Statistician: Keith Morgen, NDRIStatistician: Keith Morgen, NDRI

Operations: Virginia Stanick, and Marie Marthol, NDRIOperations: Virginia Stanick, and Marie Marthol, NDRI

Field: Jeffrey Becker, Wanda Bonilla, Nadina Correa, Una Cruz, Field: Jeffrey Becker, Wanda Bonilla, Nadina Correa, Una Cruz, Doug Goldsmith, , Myrta Hernandez, Yolanda Jones, Vanessa Doug Goldsmith, , Myrta Hernandez, Yolanda Jones, Vanessa Rodriguez, Scott Smith, Luis Torres, NDRIRodriguez, Scott Smith, Luis Torres, NDRI

Design: Evette McCoy, NDRIDesign: Evette McCoy, NDRI

BackgroundBackground

This presentation draws on This presentation draws on prospective and retrospective findings from three prospective and retrospective findings from three NIDA-F studies using both quantitative and qualitative methods to explore NIDA-F studies using both quantitative and qualitative methods to explore the recovery experience over time as well as factors that promote and the recovery experience over time as well as factors that promote and hinder the process. hinder the process.

The studies were/are conducted among inner-city participants in New York The studies were/are conducted among inner-city participants in New York City (details in handouts):City (details in handouts):

Pathways to long-term abstinence: Self-help processes, R01DA14409Pathways to long-term abstinence: Self-help processes, R01DA14409

Twelve-step as aftercare: predictors and effectiveness, R01DA015133-Twelve-step as aftercare: predictors and effectiveness, R01DA015133-

Referral to self-help: Clients’ and clinicians’ views, R03 DA13432Referral to self-help: Clients’ and clinicians’ views, R03 DA13432

Pathways Pathways Study SampleStudy Sample (N = 354) (N = 354)::SummarySummary (see handouts) (see handouts)

Primarily members of inner-city ethnic, underserved minoritiesPrimarily members of inner-city ethnic, underserved minorities

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

Almost all are polysubstance usersAlmost all are polysubstance users

Self-identified as ‘in recovery’ from one month to 10+ yearsSelf-identified as ‘in recovery’ from one month to 10+ years

30% HepC+ and 22% HIV+30% HepC+ and 22% HIV+

Almost all have used formal addiction treatment services Almost all have used formal addiction treatment services andand 12-step fellowships12-step fellowships

Key PointsKey Points

Need to make recovery a bona fide topic of researchNeed to make recovery a bona fide topic of research

Need to adopt long-term ‘career’ perspectiveNeed to adopt long-term ‘career’ perspective

Need to identify Need to identify multiplicity of recovery experiences, paths and multiplicity of recovery experiences, paths and chronological patterns (stages) and their determinants:chronological patterns (stages) and their determinants:

Recovery challenges, resources and unmet needs Recovery challenges, resources and unmet needs associated with the initiation, consolidation and associated with the initiation, consolidation and maintenance of recovery maintenance of recovery

66

Why study the Why study the recovery processrecovery process??

Why study the recovery processWhy study the recovery process??

The prevalent view of addiction is that it is, for many, a lifelong ‘chronic’ The prevalent view of addiction is that it is, for many, a lifelong ‘chronic’ disorder disorder

However, However, stable stable recovery is a reality for millions of peoplerecovery is a reality for millions of people

We know a great deal about active addiction patterns - there are large We know a great deal about active addiction patterns - there are large databases about lifetime, past year and past month substance usedatabases about lifetime, past year and past month substance use

We know about the process of We know about the process of recovery initiationrecovery initiation through treatment through treatment evaluation studiesevaluation studies

““Looking at treatment to understand recovery is like looking at birth to Looking at treatment to understand recovery is like looking at birth to understand life” (Bill White)understand life” (Bill White)

Why study the recovery processWhy study the recovery process? ? [2][2]          

Recovery from a chronic disorder is process unfolding over time

We know little about temporal patterns of recovery over time or about predictors of long-term recovery (recovery consolidation and maintenance)

We know virtually nothing about the size or profile of the recovering community in the US

Worse, we know little about how recovering persons achieve or maintain their status over time

The drug field lags far behind the alcoholism field where several long-term and prevalence estimates of recovery have been conducted (e.g., Vaillant as well as Dawson 2005) - although more is needed.

Why study the recovery processWhy study the recovery process? ? [3][3]

Active addiction has multiple, high costs to the individual and to society (ref. Active addiction has multiple, high costs to the individual and to society (ref. High HIV+ and HepC+ rates)High HIV+ and HepC+ rates)

Understanding the recovery process and its determinants:Understanding the recovery process and its determinants:

Inform program development and service deliveryInform program development and service deliveryInform about needed supports and resources for the recovery community Inform about needed supports and resources for the recovery community

Learning from the experiences of the recovering community can contribute to:Learning from the experiences of the recovering community can contribute to:

Give hope to active addicts and their familyGive hope to active addicts and their familyCounterbalance the stigma of active addiction that leads to discrimination Counterbalance the stigma of active addiction that leads to discrimination for recovering persons –e.g., in the work placefor recovering persons –e.g., in the work place

1010

“One of the great surprises of longitudinal research is that you discover that people do recover”

George Vaillant

1111

What does What does ‘Recovery’ mean?‘Recovery’ mean?

3%

8%

62%

22%

Public’s Perception Of “In Recovery”Public’s Perception Of “In Recovery”From Faces & Voices of Recovery – April 2004/Hart Research and Coldwater Corporation [National Random phone survey N = 801]

When you hear the word “recovery, as in “This person is in recovery from an addiction,” what does “recovery” mean?

Person is free from addiction/no longer

uses D&A

Person is trying to stop using D&A

Person has been damaged by D&A

Person has mental illness

1.4

1.7

3.1

8

85.8

Moderate/controlleduse of any drug and

alcohol

Other

No hard drugs, otherD&A OK

Not ANY drug, somealcohol

Being drug-free (Nouse of any D&A)

Pathways ParticipantsPathways Participants Recovery definition Recovery definition

Recovery definition: so what?Recovery definition: so what?

While the recovery community largely defines ‘recovery’ as the While the recovery community largely defines ‘recovery’ as the achievementachievement of drug-free status, two-thirds of the the general of drug-free status, two-thirds of the the general public defines it as an public defines it as an attemptattempt to become drug-free (can it be to become drug-free (can it be achieved?)…achieved?)…

This suggests that more work needs to be done to inform the This suggests that more work needs to be done to inform the public that public that achievingachieving drug-free recovery is a realitydrug-free recovery is a reality

Recovery patternsRecovery patterns

Few long-term studies on recovery (<2 yrs)Few long-term studies on recovery (<2 yrs)

Most conducted among Most conducted among alcohol-dependentalcohol-dependent persons persons (e.g. Vaillant)(e.g. Vaillant)

Findings suggest that although the course of Findings suggest that although the course of recovery varies across individuals, the recovery varies across individuals, the likelihood of likelihood of sustained recovery increases over timesustained recovery increases over time (I.e., the risk (I.e., the risk of relapse decreases over time)of relapse decreases over time)

Sustained drug-free recovery at F1 as a function of Sustained drug-free recovery at F1 as a function of baseline recovery stage (N = 287)baseline recovery stage (N = 287)

Pathways participantsPathways participants

43.6

57.5

86.4 84.2

Sustained recoveryF1

43.6 57.5 86.4 84.2

Under 6 mo.

Six to 18 mos.

18 to 36 mos

Three+ years

Recovery patternsRecovery patterns

Evidence that the risk of relapse remains, even after Evidence that the risk of relapse remains, even after several years of abstinence…. several years of abstinence….

We examined retrospective recovery patterns among We examined retrospective recovery patterns among Pathways participantsPathways participants

Yes71%

Pathways to Long-Term AbstinencePathways to Long-Term Abstinence Relapse HistoryRelapse History (n=354)(n=354)

Since starting regular drug use, did you ever have one or more period (s)

of complete abstinence of one month or longer followed by return

to active addiction?

Relapse HistoryRelapse HistoryNumber of clean periods followed by return to active addictionb

Over 50% reported 4 or more abstinent periods followed by return to active addiction

Range 1 to 90 Mean = 7.56; Std dev= 10.6bAmong those who report one or more such periods: N=248- 5 “don’t know”

20 & over10%

Ten to 1917%

Six to nine7%

Four to five16%

Three11%

Two 22%

One17%

Length of Length of longestlongest ‘clean’ period ‘clean’ period before return to active addictionbefore return to active addictionb

50% had one or more clean periods of one year or longer- 28% had one of 3 years or longer before slip/relapse

Ranges= 1 to 120 Mean = 23.6 Std dev= 27.9B Among those who report one or more such periods: N=253

12.3

15.5

18.3

17.1

8.3

11.5

17.0

0 5 10 15 20

Five years and over

Three to under five years

Two to under three years

One to under two years

Six to eleven months

Two to five months

One month

Length of relapse after longest Length of relapse after longest clean period clean period b

63% of respondents say relapse lasted over one year

Range = > one month to 16 yrs Mean =36.3; Std dev= 49.3 b Among those who report one or more such periods: N=253

18%

20%

11%

16%

6% 4%25%

5 yrs & over2 to under 5 yrs

One to under 2 yrsSix to 11 mons.

Two to 5 mos.One month

Under one month

Relapse patterns: RelevanceRelapse patterns: Relevance

One quarter of pathways participants are HIV+, 30% HepC+One quarter of pathways participants are HIV+, 30% HepC+

Increased likelihood of risky behaviors (e.g., unprotected sex, Increased likelihood of risky behaviors (e.g., unprotected sex, multiple partners) during active addictionmultiple partners) during active addiction

NEED TO ELUCIDATE BARRIERS TO SUSTAINED RECOVERY NEED TO ELUCIDATE BARRIERS TO SUSTAINED RECOVERY AND SUCCESFUL STRATEGIES TO SUSTAIN RECOVERYAND SUCCESFUL STRATEGIES TO SUSTAIN RECOVERY

Relapse after RecoveryRelapse after Recoverybb

What got you back to using? Top answers (<10%)What got you back to using? Top answers (<10%)

10.3

12.3

32.2

38.9

0 5 10 15 20 25 30 35 40 45

B Among those who report one or more such periods: N=253

Relapse after longest clean periodRelapse after longest clean periodbb

Lessons learnt Top answers (<10%)Lessons learnt Top answers (<10%)

B Among those who report one or more such periods: N=253

10.3

11.5

15.1

18.3

18.7

21.8

I am an addict/can't use socially

Need to address underlyingissues/express feelings

Cannot recover without support

Learn about/stay away from triggers

Being clean is a positive/drugsnegative/bad place to be

Must want recovery/work on itcontinously/make it a priority

Strategies to deal with recovery challengesStrategies to deal with recovery challengesPathways participantsPathways participantscc

Seeking support and staying focused Seeking support and staying focused

Distraction6%

Seek help/support, Talk about pb

44%

Stay focused42%

Mediate/pray8%

C Among those who report a challenge

Recovery patterns summaryRecovery patterns summary

The risk of relapse remains well into the recovery processThe risk of relapse remains well into the recovery process

Stress, exposure to triggers, temptations/urges, and belief that Stress, exposure to triggers, temptations/urges, and belief that one can control drug use are recovery challenges and key one can control drug use are recovery challenges and key factors in return to active addictionfactors in return to active addiction

Making recovery a priority, staying focused on recovery and Making recovery a priority, staying focused on recovery and seeking support are identified as helpful strategiesseeking support are identified as helpful strategies

2727

Recovery CapitalRecovery Capital

Recovery CapitalRecovery CapitalRecovery capital refers to the amount and quality of Internal and Recovery capital refers to the amount and quality of Internal and external resources that one can bring to bear to initiate and sustain external resources that one can bring to bear to initiate and sustain recovery from addictionrecovery from addiction

A number of factors have been identified as predictors of recovery A number of factors have been identified as predictors of recovery in short-term studies and constitute recovery capitalin short-term studies and constitute recovery capital

They include:They include:

Cognitive recovery readinessCognitive recovery readiness

Participation in 12-step fellowshipsParticipation in 12-step fellowships

Faith/spirituality/life meaningFaith/spirituality/life meaning

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Recovery CapitalRecovery Capital

Cognitive recovery readinessCognitive recovery readiness

Cognitive recovery readinessCognitive recovery readinessCognitive domains associated with enhanced recovery outcomes in Cognitive domains associated with enhanced recovery outcomes in process research include: process research include:

Generic processes common to several addiction treatment Generic processes common to several addiction treatment orientations such orientations such as drug abstinence self-efficacy, motivation and as drug abstinence self-efficacy, motivation and copingcoping; and; and

Processes that are unique to the disease (Minnesota) model:Processes that are unique to the disease (Minnesota) model:Embracing the disease view of addiction as a lifelong disorderEmbracing the disease view of addiction as a lifelong disorderAdmitting powerlessness over drugs and alcohol, Admitting powerlessness over drugs and alcohol, Accepting the need for/believing in a Higher power, Accepting the need for/believing in a Higher power, Commitment to 12-step fellowships (intention to attend 12-Commitment to 12-step fellowships (intention to attend 12-step groups), andstep groups), and identifying with others in recovery. identifying with others in recovery.

Increasing/higher levels of these cognitive processes found to be Increasing/higher levels of these cognitive processes found to be associated with better subsequent substance use outcomes. associated with better subsequent substance use outcomes.

Cognitive Recovery Readiness Cognitive Recovery Readiness across Stages of Changeacross Stages of Change

Disease model beliefs + motivation and coping

(i.e., all but self-efficacy)

STAGE OF CHANGE

ActionContemplationPrecontemplation

Mea

n sc

ore

(sca

le r

ange

= 1

to 5

) 4.2

4.0

3.8

3.6

3.4

Asbtinence

self-efficacy

Recovery readiness*

Cognitive Recovery Readiness Cognitive Recovery Readiness as a function of help seeking careeras a function of help seeking career

Prior treatment here – same trend with prior 12-step attendancePrior treatment here – same trend with prior 12-step attendance

Abstinence

self-efficacy

Recovery readiness*

NUMBER PRIOR TREATMENT EPISODES

10+5-93-4TwoOneNone

Mea

n sc

ore

5.0

4.5

4.0

3.5

3.0

2.5

* Disease model beliefs + motivation and coping

(i.e., all but self-efficacy)

So, Cognitive recovery readiness…So, Cognitive recovery readiness…

Increases over stages of change

Increases as a function of cumulative recovery help seeking (treatment and 12-step)

3434

Recovery CapitalRecovery Capital

12-step fellowships12-step fellowships

BackgroundBackground

• In the United States, 12-step groups (e.g., Alcoholics and In the United States, 12-step groups (e.g., Alcoholics and Narcotics Anonymous) are both Narcotics Anonymous) are both the most prevalent types of the most prevalent types of self-help groups and the most common source of helpself-help groups and the most common source of help sought sought by people with substance abuse problems.by people with substance abuse problems.

• Participation in 12-step groups during and after formal Participation in 12-step groups during and after formal treatment associated with reduced rates of substance usetreatment associated with reduced rates of substance use

• Concurrent use of 12-step and formal treatment has been Concurrent use of 12-step and formal treatment has been shown to have additive effects shown to have additive effects

12-step affiliation and sustained recovery12-step affiliation and sustained recovery

Effectiveness: Twelve step affiliation (attendance and Effectiveness: Twelve step affiliation (attendance and involvement) significantly associated with involvement) significantly associated with subsequent positive (sustained) recovery outcome…subsequent positive (sustained) recovery outcome…

Effectiveness: Sustained abstinent recovery at F1 as Effectiveness: Sustained abstinent recovery at F1 as a function of baseline level of 12-step attendance a function of baseline level of 12-step attendance

and affiliationand affiliation

Consider self member

Stepwork

Attended 12-step

past yr

Sustained abstinent recovery at F1

Sustained recoveryNo

.8

.7

.6

.5

.4

.3

3838

12-step attendance: 12-step attendance: Patterns and attritionPatterns and attrition

12-step Attendance patterns12-step Attendance patternsAftercare participants Aftercare participants (N = 314)(N = 314)

Never attended

19%

Attended past year

58%

Disengaged23%

12-step attrition: Ever dropped out?12-step attrition: Ever dropped out?

85%91%

0%

25%

50%

75%

100%

NarcoticsAnonymous

AlcholicsAnonymous

Since you fist started attending, have you ever stopped attended for one month or longer? (yes)

4141

Perceived helpfulness Perceived helpfulness and benefits of 12-step and benefits of 12-step

groupsgroups

Attitudes about 12-step among Drug Attitudes about 12-step among Drug Treatment patients Treatment patients e

7.86

8.02

8.70

7.4 7.6 7.8 8 8.2 8.4 8.6 8.8

Importance of12-step inrecoveryprocess

Importance of12-step intreatment

Helpfulness of12-step

e Scale range from 0 to 10

59

33

4

3

41

58

4

8

0 20 40 60

Promotes recovery

Support/acceptance/fe

llo...

To make fri

ends, to check ..

Step work, spirit

uality

Narcotic Anonymous

Alc. Anonymous

Reasons for 12-step attendanceReasons for 12-step attendanceff ,g ,g

F among ‘ever’ attenders; g Add to < 100% because up to 3 answers were coded

Quandary: Quandary: 12-step attrition and non-affiliation12-step attrition and non-affiliation

12-step fellowships generally viewed as helpful and beneficial 12-step fellowships generally viewed as helpful and beneficial to recoveryto recovery

Yet, some never attend and many disaffiliate over timeYet, some never attend and many disaffiliate over time

One of the most important tasks for clinicians is to foster One of the most important tasks for clinicians is to foster stable engagement in 12-step groups to facilitate patients’ stable engagement in 12-step groups to facilitate patients’ transition into the post-treatment phase of recovery. transition into the post-treatment phase of recovery.

What are some of the reasons why substance users do not What are some of the reasons why substance users do not attend/leave 12-step?attend/leave 12-step?

4545

Obstacles to 12-step Obstacles to 12-step affiliation and reasons affiliation and reasons

for non-attendancefor non-attendance

Why did you stop attending 12-step?Why did you stop attending 12-step?(longest interrupted period)(longest interrupted period)gg

3326 25

15 13 5

G Add to < 100% because up to 3 answers were coded

Observation…Observation…

Reasons cited for not attending 12-step groups mirror the Reasons cited for not attending 12-step groups mirror the lessons learnt from relapse and helpful strategies to recover:lessons learnt from relapse and helpful strategies to recover:

Don’t want to stop vs. make recovery a priorityDon’t want to stop vs. make recovery a priority

Can do it on my own vs. seek supportCan do it on my own vs. seek support

THIS SUGGESTS THAT MOTIVATION AND ACCEPTING NEED THIS SUGGESTS THAT MOTIVATION AND ACCEPTING NEED FOR/SEEKING SUPPORT FOR RECOVERY ARE CRITICAL FOR/SEEKING SUPPORT FOR RECOVERY ARE CRITICAL

4848

Recovery CapitalRecovery Capital

Spirituality, Faith and Life meaningSpirituality, Faith and Life meaning

Baseline Spirituality, Religiosity, Life meaning Baseline Spirituality, Religiosity, Life meaning and Recovery @ F1and Recovery @ F1

Sustained abstinent recovery at F1

YesNo

Me

an

6.0

5.5

5.0

4.5

4.0

3.5

3.0

2.5

Spiritual well-being

Life meaning

Religiosity

Pathways PilotPathways PilotSpirituality and religion as Recovery support (N=52)Spirituality and religion as Recovery support (N=52)

2

8

10

12

14

16

33

34

38

0 5 10 15 20 25 30 35 40

Community invoolvment,volunteer work/service

Surrender/admittedpowerlessness

None

God (non-specific)

Support from peers

Spiritualawakening/experience

Spiritual God/HigherPower/spirituality

12-step recovery program andfellowship

Organized religion, church

h Adds up to < 100% because up to 3 answers were coded

Describe any religious/spiritual experience/ support that you have had as a significant part of your recoveryh

Pathways to Long-Term AbstinencePathways to Long-Term Abstinence Sources of strength and support in recoverySources of strength and support in recoveryaa

7

11

17

18

43

53

53

0 10 20 30 40 50 60 70 80 90 100

So, spirituality/religion…So, spirituality/religion…

Cited as critical source of recovery support Cited as critical source of recovery support

Associated with sustained recovery over timeAssociated with sustained recovery over time

5353

Why do substance users Why do substance users seek recovery?seek recovery?

Pathways to Long-Term AbstinencePathways to Long-Term AbstinenceFactors Associated with Decision to QuitFactors Associated with Decision to Quit

83

86

90

92

93

94

50 75 100

Negative effects of drug use onothers

Weighing pros & cons ofcontinued use

Didn't like what I was becoming

Tired of the drug life

Desire for a better life

Didn't like where life wasgoing/feared consequences

“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.”

Recovery: The hard road to a better life?Recovery: The hard road to a better life?

Many recovering substance users report that they stopped using Many recovering substance users report that they stopped using drugs because they wanted a better life. drugs because they wanted a better life.

They see initiating recovery as the path to a better lifeThey see initiating recovery as the path to a better life

It is a challenging and stressful path for mostIt is a challenging and stressful path for most

We conducted a study that addressed two questionsWe conducted a study that addressed two questions

First: First: Does quality of life improve as recovery Does quality of life improve as recovery progresses? progresses?

Stress and Life Satisfaction as a Stress and Life Satisfaction as a Function of Length of RecoveryFunction of Length of Recovery (N = 354)

RECOVERY STAGE

3+ years18 to 36 mos

Six to 18 mos>6 months

Mean

(sc

ale ran

ge =

0 to

10)

8.5

8.0

7.5

7.0

6.5

6.0

5.5

5.0

Overall life

satisfaction

Stress rating pst yr

Does recovery capital buffer stress Does recovery capital buffer stress among persons in recovery?among persons in recovery?

Stress frequently cited as a relapse triggerStress frequently cited as a relapse trigger

Second question: Do factors previously identified separately as Second question: Do factors previously identified separately as buffering stress or promoting stable recovery contribute to buffering stress or promoting stable recovery contribute to enhancing QOL among recovering personsenhancing QOL among recovering persons

We tested a model that hypothesized that We tested a model that hypothesized that RECOVERY RECOVERY CAPITALCAPITAL -social support, spirituality, life meaning, religious -social support, spirituality, life meaning, religious practices, and affiliation with 12-step fellowships - practices, and affiliation with 12-step fellowships - buffers buffers stress and enhance quality of life satisfaction.stress and enhance quality of life satisfaction.

We found…We found…

Recovery capital: Buffering Stress Recovery capital: Buffering Stress and Enhancing Quality of Life in recoveryand Enhancing Quality of Life in recovery jj ( (N = 354)N = 354)

Stress

Spirituality 17%

General Social suprt 9.6%

Length of recovery 9.1%

Religiousness 8.5%

Recovery support 7.3%

Life meaning 5.6%

12-step involvement 3.5%

12-step attendance 0

Quality of life

jj All betas p<.001 except 12-step attendance

RECOVERY CAPITAL ACCOUNTS FOR 60.6% OF VARIANCE IN QOLRECOVERY CAPITAL ACCOUNTS FOR 60.6% OF VARIANCE IN QOL

Recovery capital as predictor of Recovery capital as predictor of sustained abstinent recovery at F1sustained abstinent recovery at F1

We conducted a preliminary examination of predictors of sustained abstinent recovery We conducted a preliminary examination of predictors of sustained abstinent recovery at F1 to determine whether the same or different factors predict sustained recovery at at F1 to determine whether the same or different factors predict sustained recovery at different stages of the processdifferent stages of the processMultiple regression analyses were conducted on the whole sample and on each of the Multiple regression analyses were conducted on the whole sample and on each of the four baseline recovery stage groupsfour baseline recovery stage groupsHypothesized baseline predictors of sustained abstinent recovery @ F1:Hypothesized baseline predictors of sustained abstinent recovery @ F1:

Lifetime severityLifetime severityLength of recovery @ baseLength of recovery @ baseCommitment to abstinenceCommitment to abstinenceSelf efficacySelf efficacy12-step involvement12-step involvementEmbracement disease modelEmbracement disease model12-step attendance past yr12-step attendance past yrRecovery supportRecovery supportSpiritual well-beingSpiritual well-beingReligiosityReligiosityLife meaningLife meaningLife satisfaction Life satisfaction Stress past monthStress past month

39%

21%

21%

27%

Under 6 mos.

6 to 18 mos.

18 to 36 mo.

Three+ yrs

Predictors of sustained Predictors of sustained recovery @ F1: recovery @ F1: Total sample and baseline recovery stages Total sample and baseline recovery stages N = 287N = 287

Predictors of sustained recovery appear to differ across recovery stages…Predictors of sustained recovery appear to differ across recovery stages…

TotalTotal > 6 months> 6 months 6 to 18 mos.6 to 18 mos. 18 to 36 mos. 18 to 36 mos. 3 yrs +3 yrs +

    % variance explained% variance explained 15%15% 23%23% 32%32% 12%12% 15%15%  Lifetime severityLifetime severity xx xx nsns xx nsnsLength of recovery @ baseLength of recovery @ base xx xx xx nsns nsnsCommitment to abstinenceCommitment to abstinence nsns nsns xx nsns xxEmbracement disease modelEmbracement disease model nsns xx nsns nsns nsns12-step attendance pst yr12-step attendance pst yr nsns xx nsns nsns nsnsRecovery supportRecovery support nsns xx nsns nsns nsnsReligiosityReligiosity nsns nsns nsns xx xx

Life meaningLife meaning xx nsns nsns nsns xx

Predictors of sustained recoveryPredictors of sustained recovery

Preliminary findings suggest that different sets of factors are associated with sustained recovery at different recovery stages

Much of the variance in sustained recovery remains unexplained and much more work is needed

6262

Recovery revisited…Recovery revisited…

Beyond drug use & abstinenceBeyond drug use & abstinence

6363

““If you want to treat an illness that has no If you want to treat an illness that has no easy cure, first of all, easy cure, first of all, treat them with hopetreat them with hope””

George VaillantGeorge Vaillant

Recovery definition revisitedRecovery definition revisited Pathways participantsPathways participantsgg

How would you define "recovery from drug and alcohol use"? How would you define "recovery from drug and alcohol use"? Please be as specific as you can. [RECORD VERBATIM]Please be as specific as you can. [RECORD VERBATIM]

RECOVERY GOES BEYOND SUBSTANCE USERECOVERY GOES BEYOND SUBSTANCE USE

24

24

31

72

0 10 20 30 40 50 60 70 80

Dealing with issues/seeking help

Lifelong process/working on self

Total abstinence

Better life/new life

G Add to < 100% because up to 3 answers were coded

Positive aspects of recoveryPositive aspects of recovery Pathways participantsPathways participantsgg

9

10

17

21

49

62

0 10 20 30 40 50 60 70

G Add to < 100% because up to 3 answers were coded

Integration of FindingsIntegration of Findings  

Achieving sustained recovery is a reality Achieving sustained recovery is a reality

Recovery appears to be the road to a better life Recovery appears to be the road to a better life

There are many challenges along the way: stress, urges to use, denial of problemThere are many challenges along the way: stress, urges to use, denial of problem

There are potentially costly slips and relapses along the wayThere are potentially costly slips and relapses along the way

Keeping focused on recovery, learning to deal with stress, and seeking support are Keeping focused on recovery, learning to deal with stress, and seeking support are key to maintaining recoverykey to maintaining recovery

This translates into the need for ‘recovery capital’: motivation, accepting the problem This translates into the need for ‘recovery capital’: motivation, accepting the problem and working on it (12-step ideology), seeking support from peers (e.g., 12-step and working on it (12-step ideology), seeking support from peers (e.g., 12-step fellowships), faith, and a sense of meaning/purposefellowships), faith, and a sense of meaning/purpose

Although recovery in the US is largely defined as “abstinence from all drugs and Although recovery in the US is largely defined as “abstinence from all drugs and alcohol”, the recovery experience goes beyond substance use and represents a new alcohol”, the recovery experience goes beyond substance use and represents a new life, a better life, new hopes and opportunitieslife, a better life, new hopes and opportunities

Preliminary evidence indicates that different factors are critical to recovery at different Preliminary evidence indicates that different factors are critical to recovery at different ‘stages’  ‘stages’  

6767

Looking forward…Looking forward…

MEASUREMENT and RESEARCH ISSUESMEASUREMENT and RESEARCH ISSUES

Defining RecoveryDefining RecoveryIs recovery a time-limited event (a state) or a time-extending process? If addiction is a Is recovery a time-limited event (a state) or a time-extending process? If addiction is a chronic disorder, recovery may be a process unfolding through (below) non mutually chronic disorder, recovery may be a process unfolding through (below) non mutually exclusive stages – from partial to full remission?exclusive stages – from partial to full remission?

When is recovery achieved? Under what circumstances is it lost or brought to When is recovery achieved? Under what circumstances is it lost or brought to completion?completion?

DSM-IV-R – Possible recovery stages from partial to full remissionDSM-IV-R – Possible recovery stages from partial to full remissionSub- clinical:Sub- clinical: Past year user who d Past year user who does not meet the DSM-IVR criteria for dependence oes not meet the DSM-IVR criteria for dependence butbut reported 1+ symptoms of either abuse or dependence? reported 1+ symptoms of either abuse or dependence?

Problematic use:Problematic use: Past-year risk user (see above) with no symptoms of either abuse Past-year risk user (see above) with no symptoms of either abuse or dependence in the past 12 months?or dependence in the past 12 months?

Non- problematic use:Non- problematic use: Past year substance user with no symptoms of either abuse Past year substance user with no symptoms of either abuse or dependence and not classified as a past-year risk user? or dependence and not classified as a past-year risk user? 

No use:No use: No past year substance use (complete abstinence)? No past year substance use (complete abstinence)?

Investigating Recovery: How?Investigating Recovery: How?

The empirical investigation of the recovery experience over time The empirical investigation of the recovery experience over time requires requires methods that differ from those typically used when methods that differ from those typically used when conducting treatment evaluation studiesconducting treatment evaluation studies. .

For example….For example….

RECRUITMENT RECRUITMENT Persons in recovery are “from all walks of life.”Persons in recovery are “from all walks of life.”Recruiting a representative sample of recovering persons Recruiting a representative sample of recovering persons requires strategies that cast a wide net across ethnic groups, requires strategies that cast a wide net across ethnic groups, social strata, substance use histories and recovery paths. social strata, substance use histories and recovery paths. Media advertisementMedia advertisement has been the most frequently used and the has been the most frequently used and the most effective strategy for recruiting diversified samples of most effective strategy for recruiting diversified samples of recovering persons (see handout)recovering persons (see handout)

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We’ve only just begun…We’ve only just begun…

Where do we go from here?Where do we go from here?   

Toward a Recovery-Oriented Research AgendaToward a Recovery-Oriented Research Agenda  

1.1. Use a telescope, not a microscope (George Vaillant)Use a telescope, not a microscope (George Vaillant) – I..e.,

Adopt a long-term, natural history ‘career’ perspective to elucidate:Adopt a long-term, natural history ‘career’ perspective to elucidate:Multiplicity of recovery experiences, paths and chronological patterns (stages) Multiplicity of recovery experiences, paths and chronological patterns (stages) Determinants (promoting/hindering factors) of these paths and patterns over Determinants (promoting/hindering factors) of these paths and patterns over time time Among subgroups as the recovery experience/paths/needs may differ: e.g, Among subgroups as the recovery experience/paths/needs may differ: e.g, gender, ethnicity and age groups, HIV+, dual-diagnosis, gender, ethnicity and age groups, HIV+, dual-diagnosis, high/low problem high/low problem severity, high/low recovery capitalseverity, high/low recovery capitalAcross cultures where different socio-political views of addiction and different Across cultures where different socio-political views of addiction and different models/options of service delivery prevail models/options of service delivery prevail (‘universal’ and culture-specific (‘universal’ and culture-specific factors)factors)

2. 2. Achieve consensus on how to define and measure recoveryAchieve consensus on how to define and measure recovery In terms of substance use; and inIn terms of substance use; and in Global health, e.g., physical, emotional, relational, and occupational health and Global health, e.g., physical, emotional, relational, and occupational health and

responsible citizenshipresponsible citizenship

Toward a Recovery-Oriented Research AgendaToward a Recovery-Oriented Research Agenda

3. 3. Identify challenges, professional & indigenous resources and unmet Identify challenges, professional & indigenous resources and unmet needs associated with the initiation, consolidation and maintenance of needs associated with the initiation, consolidation and maintenance of recovery recovery

e.g., What sources of support are being used in addition to those e.g., What sources of support are being used in addition to those previously identified (treatment, 12-step) such as faith, community previously identified (treatment, 12-step) such as faith, community involvementinvolvementRole of family in Role of family in the individual recovery process as well as stages the individual recovery process as well as stages of family recovery (family as whole and family subsystems)of family recovery (family as whole and family subsystems)Role of stigma as obstacle to recovery Role of stigma as obstacle to recovery initiation and maintenanceinitiation and maintenance

4. 4. Assess the long-term consequences of various recovery pathsAssess the long-term consequences of various recovery paths (e.g., (e.g., psychosocial and cognitive/brain functioning in medically-assisted vs. psychosocial and cognitive/brain functioning in medically-assisted vs. drug-free recovery) drug-free recovery)

  5. 5. Integrate empirical findings about the recovery process into existing Integrate empirical findings about the recovery process into existing

knowledge about addiction to promote:knowledge about addiction to promote:   A paradigm shift in service delivery and assessment from the A paradigm shift in service delivery and assessment from the

current ‘acute’ model to sustained recovery managementcurrent ‘acute’ model to sustained recovery management• Societal awareness about the reality and hope of recovery and the Societal awareness about the reality and hope of recovery and the

multiple pathways to long-term recoverymultiple pathways to long-term recovery