4-1 Panel When Your PHP Fails to Exist Curtis Vixie, DDS, Tom Specht, MD, James Tracy, DDS, Harry L. Haroutunian, MD

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1 4-1 Panel When Your PHP Fails to Exist Curtis Vixie, DDS, Tom Specht, MD, James Tracy, DDS, Harry L. Haroutunian, MD

2 Background Recovery and Social Factors Dr David McCartney M.B. Ch.B., MRCGP, MSc Clinical Lead, LEAP Primary Care Addiction Specialist Masters Scottish Government Lothians & Edinburgh Abstinence Programme (Clinical Lead) Declaration of interests Granny and eggs alert! Writing Fitness Gardening Movies djmac.co.uk Format 1. Scottish context 1. Scottish Context (or whit ye need tae ken) 2. Do people get better? 3. What is recovery? 4. What s the evidence? 5. How does recovery happen? 6. Social influence, visibility and contagion

3 From Edinburgh to CO Drugs in Scotland Edinburgh to CO Population: 5M 54,000 problem heroin users (Twice rate of England and five times that of USA) 22,000 on methadone 50,000 children affected 584 drug related deaths in 2011 (485 in 2010) Stimulants/legal highs on increase Cost: 3.5 Billion ($5.44 billion) Alcohol in Scotland Chronic liver disease and cirrhosis mortality rates per 100,000 population, men and women yrs, % of men & 23% of women drinking to excess (self-reported) Average/week (men & women >16 = 23 units 5% of population dependent on drink >65,000 children affected Cirrhosis rates have doubled Cost to society: 3.56 billion ($5.53 billion) Age standardised mortality rate per 100,000 Men aged years 80 Scotland 70 Other European 60 countries England 10 and Wales Women aged years Scotland 30 Other European countries England and Wales [Source: updated from Leon and McCambridge, Lancet, 2006] Alcohol related deaths What does it mean? 15 of the 20 local areas in the UK with highest male alcoholrelated death rate are in Scotland: 1. Glasgow City 2. Inverclyde 3. West Dunbartonshire 4. Renfrewshire 5. Dundee City It means we have a problem! (Office for National Statistics)

4 2. Do people get better? Desistance (crime) Nothing works 85% of repeat offenders desist from criminality by the age of 28 (Blumstein and Cohen, 1987) Most of the research suggests that desistance occurs away from the criminal justice system. That is to say that very few people actually desist as a result of intervention on the part of the criminal justice system or its representatives (Ward and Maruna, 2007) Recovery rates Outcomes (US) Physicians CSAT (2009): 58% of life-course dependent users of substances will achieve lasting recovery Welsh workers estimate: 7% 80%+ sustained abstinence 70% return successfully to work High expectation Intensive treatment Monitoring Lothians & Edinburgh Abstinence Programme Seven pillars of LEAP Medical Therapeutic Housing (safe, supported) Education/employability Mutual aid/recovery community Family programme Aftercare

5 LEAP stats. Do people get better? 300 referrals/year 112 admissions/yr ~62% completion 52% graduates maintain abstinence (one year on) Yes! 3. What is recovery? What do we mean by recovery? voluntarily sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society (UK Drug Policy Commission, 2008, p6) Recovery is a process through which an individual is enabled to move on from their problem drug use towards a drug-free life and become an active and contributing member of society (Scottish Government 2008) What do we mean by recovery? 4. What s the evidence? Betty Ford Institute Consensus Panel (2007, p. 222) defined recovery as a voluntarily maintained lifestyle characterised by sobriety, personal health and citizenship. You are in recovery if you say you are (Valentine, 2011)

6 Evidence review But There is little UK-based research and the international evidence base on recovery is limited by three factors: 1.Much of the evidence is dated; 2.Much of it is based on alcohol rather than illicit drugs; and 3.Almost all the evidence originates from the United States. Sustained recovery is the norm Recovery capital is a predictor of sustained recovery Treatment plays a part Strong evidence around 12-step linkage Families and communities important Research for Recovery, Scottish Government (2010) Research for Recovery, Scottish Government (2010) Study of workers in the field in recovery from heroin addiction (n=108) Mapping the recovery journeys of former drinkers in recovery Hibbert and Best (2011, Drug and Alcohol Review) 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) Post-traumatic growth From natural disasters like tornadoes, plane crashes and murders (McMillan et al, 1997); sexual assault (Frazier et al, 2004); bereavement (Saka, 2008); terror attacks (Ai and Park, 2005) Manifested as more intimate with loved ones; a clearer sense of self-identity; appreciating life more, more courage to try new things Hardship is no longer seen as a purposeless experience but contributing to a different view of the world, discovery of hidder inner strengths, and renewed evaluation of relationships

7 5. How does recovery happen? Why do people recover? Moos (2011) MODEL MEANING 1. Social control Bonding and support; goal direction (from family, friends, etc); structure and monitoring 2. Social learning Observation and imitation of family, peers and mentors; learning positive and negative consequences 3. Stress and coping Building self-efficacy and selfconfidence; developing effective coping skills 4. Behavioural economics Involvement in protective activities alternative rewarding activities Structural equation modeling results from over 2,000 patients assessed at intake, 1-year, 2-year Getting plugged in makes you well Self-Help Group Involvement Active Coping Motivation to change General Friendship Quality Friends Support For Abstinence Reduced Substance Use Holt-Lunstad & colleagues (2010) Grella & colleagues (2008) Best & Laudet (2010) Litt & colleagues (2009) Note All paths significant at p<.05. Goodness of Fit Index =.950. Litt et al Changing network support for drinking (2009) Recovery studies in Birmingham and Glasgow (Best et al, 2011a; Best et al, 2011b) 186 participants randomised to network support (NS) or case management (CM) 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 More time spent with other people in recovery More time in the last week spent: Childcare Engaging in community groups Volunteering Education or training Employment

8 Recovery capital Recovery-oriented practice Inspire hope and belief Building recovery capital Care and recovery coordination Aftercare and visibility Assertive linkage Assertive referral to mutual aid So how are we doing? (Also known as the gap ) Find out what meetings are available Match the patient to the meeting Encourage patient to phone helpline or active member now Or get someone to take Follow up and encourage to continue Edinburgh needs assessment AOD service users surveyed Do you use or have you ever used AA/NA? AA = 0.8% NA = 0.4% Why are we so appalling at bridging the gap? (Figure 8, 2010) 6. Social influence, visibility & contagion Framingham Heart Study Christakis and Fowler A person s odds of becoming obese increased by 57% if they had a friend who became obese, with a lower risk rate for friends of friends, lower again at three degrees of separation No discernible effect at further levels of remove Smoking cessation by a spouse decreased a person s chances of smoking by 67%, while smoking cessation by a friend decreased the chances by 36%. The average risk of smoking at one degree of separation (i.e., smoking by a friend) was 61% higher, 29% higher at two degrees of separation and 11% higher at three degrees of separation.

9 The Obesity Epidemic The obesity epidemic 64.3% Scots are overweight or obese 66% of Americans are overweight or obese From 1990 to 2000, the percentage of obese people in the USA increased from 21% to 33% Your Friends Friends Can Make You Fat Photos by Colin Rose and Sherrie G Obesity is catching Traditional Scottish Lunch Green Node = non-obese Yellow Node = obese (size of circle is proportional to BMI) Social networks and quality of life Holt-Lunstad et al (2010): meta-analysis: individuals with adequate social relationships have a 50% greater likelihood of survival compared to those with poor or insufficient social relationships (p.14) Participation in groups is associated with less psychological distress (Ellaway and MacIntyre, 2007) Youth Cohort Study (Best et al, 2012): Fewer friends associated with greater psychological distress Maintenance of a using friendship network associated with ongoing use and life problems 12 Step Affiliation versus involvement Attendance at 12 Step meetings is not likely to be as helpful as becoming actively involved in the 12 Step community. Finding a sponsor associated with a four fold decrease in drinking at 6 months Tonigan & Rice (2010)

10 Recovery communities: what are they? UK Recovery Walk, Glasgow, 2010 Local recovery communities Edinburgh Contagion Have treatment providers got it the wrong way round? Recovery is contagious Recovery champions What does it all mean? General Recovery is a reality Recovery is social Recovery is contagious The worldwide evidence base needs to develop a bit We can actively connect people into recovery resources (build capital) Programme Evidence: recovery narratives Takes place in 12-step groups Attraction; power of example 12 step evidence strong and growing 12th step; assertive linkage; IDAA Mutual aid (120) Serenity cafe Women s groups Recreational SUGs (service user groups) Further reading and acknowledgements Research for Recovery LEAP & the Recovery Community in Edinburgh (McCartney, D, Journal of Groups in Addiction and Recovery: Vol 6, Issue 1-2, 2011) The Potential of Recovery Capital (Best, Laudet, RSA, 2010) Thanks to: Randy Adair; David Best; Dawn Obrecht; Ian Sharman

11 Dr David McCartney

12 Biography: Dr David McCartney David is currently the Clinical Lead at Lothians & Edinburgh Abstinence Programme, a partnership NHS/Council/Voluntary sector project for clients living in the Lothian area in Scotland. LEAP is a quasi-residential treatment initiative with twenty substance dependent individuals in active treatment and around 60 attending aftercare at any time. The service embraces an integrated bio-psycho-social approach to addiction and recovery and attempts to integrate treatment with housing, education, training, employability and peer-support networks in Lothian. David s background is in inner-city general practice in Glasgow, Scotland. Following retraining in addictions he now works exclusively as a Primary Care Addiction Specialist in clinical and management roles. Previously a tutor on the Royal College of General Practitioners Substance Misuse Management course, he has a Master s degree in Alcohol and Drug Studies researching how doctors recover from dependent drug use. He is interested in the neurobiology of addiction, the place of mutual aid and recovery communities in the recovery process and also in recovery-orientated treatment approaches to treating those with addictive disorders. He enjoys teaching patients, medical and postgraduate students and primary care practitioners on these subjects. David is a member of the Royal College of General Practitioners. He is also a member of the Drugs Strategy Delivery Commission in Scotland which scrutinises the Scottish Government s application of drugs policy, sits on the Government s Drug and Alcohol Delivery Group and is a Fellow of the RSA.