RECOVERY ORIENTED SYSTEMS OF CARE

Transcription

1 RECOVERY ORIENTED SYSTEMS OF CARE April 24, 2014 Chris Budnick, MSW, LCSW, LCAS, CCS The Healing Place of Wake County Recovery Communities of North Carolina Presentation Goals 1. Highlight the emergence of recovery as an organizing paradigm for the addiction treatment field 2. Outline the shift from an acute care (AC) model of intervention to a model of sustained recovery management (RM) THPWC & RCNC I. History of AOD Studies The Healing Place of Wake County (THPWC) is a 501(c)(3) homeless shelter that offers: Overnight emergency shelter Non medical detoxification; and A long term, 12 step based, peer run recovery program for persons with alcoholism and other drug addictions Recovery Communities of North Carolina Promoting Addiction Recovery, Wellness and Citizenship through Advocacy, Education and Support The study of alcohol and other drugs (AOD) has gone through various stages where different aspects of AOD problems were the focus of public and professional debate and research. Pathology paradigm Intervention paradigm Recovery paradigm Introduction Pathology Paradigm Based upon presentation given by William L. White, M.A. and Iejoma Achara, Psy.D. at the Recovery Oriented Systems of Care (ROSC) Symposium in Atlanta, GA in 2009 Focused upon: Whether alcoholism was a sin or sickness The incidence, prevalence, effects/costs of AOD problems Understanding the causes of AOD problems 1

2 Intervention Paradigm Recovery Paradigm Focused on: Preventing AOD problems Controlling drug supplies Punishing drug offenders Treating those with severe AOD problems Focus on: The prevalence and patterns of long term recovery from AOD problems Exploring the growing varieties of pathways and styles through which people are resolving serious and persistent AOD problems At risk individuals, families and communities who have avoided the development of severe AOD problems Origins of ROSC II. Driving this Paradigm Shift 1998 William L. White and Searcy W. 1. A loss of recovery focus through professionalization 2. Science based conceptualizations of addiction as a chronic disorder (Hser et al., 1997; McLellan et al., 2000; Dennis & Scott, 2007) 3. Accumulation of systems performance data on limitations of acute care (AC) model of addiction treatment (White, 2008) Recovery Paradigm 1. Loss of Recovery Focus Calls for a recovery focused research agenda (White, 2000; White & Godley, 2007, White & Chaney, 2009; White & Schulstad, in press) 2

3 Early Recovery Advocacy Advocacy Vision vs. Reality Mrs. Marty Mann 1944 National Committee on Alcohol Education (today National Council on Alcoholism and Drug Dependence) Recovery TX Vision Treatment Recovery Reality 2014 National Committee on Alcohol Education The core messages of NCAE included: Bill White Atlanta 2009 Loss of recovery focus Alcoholism is a disease The alcoholic is a sick person The alcoholic can be helped and is worthy of helping Alcoholism is public health problem and therefore a public responsibility Senator Harold Hughes & Marty Mann Comprehensive Alcohol Abuse and Alcoholism Prevention and Rehabilitation Act of

4 Focus of Recovery Paradigm Implications A focus of this recovery paradigm is reconnecting treatment with the more enduring communities and process of recovery. For persons with diabetes, hypertension or asthma A recurrence of symptoms following treatment cessation is considered evidence of treatment effectiveness This is used to justify devoting resources to continuing treatment For persons with substance use disorders A recurrence of symptoms following treatment cessation has been considered evidence of treatment failure This is used to justify not investing further resources into treatment 2. Addiction as a Chronic Illness Further Considerations Should addiction be considered a chronic illness, similar to hypertension, diabetes, or asthma? Important Article Addiction and Recovery Careers McLellan, A. T., Lewis, D. C., OʹBrien, C. P., & Kleber, H. D. (2000). Drug Dependence, a Chronic Medical Illness: Implications for Treatment, Insurance and Outcomes Evaluation. Journal of the American Medical Association, (284)13, Makes the case that addiction should be considered a chronic illness Dennis et al. (2005) conducted a large study with 1,271 participants recruited from different agencies in west side of Chicago between 1996 and

5 Addiction and Treatment Careers Implications The purpose of this study was to estimate the duration and correlates of years between: Most persons who develop a substance use disorder have substance related problems for years First use and at least a year of abstinence First treatment admission and at least one year of abstinence Substance use careers are longer the earlier the age of first use Addiction and Treatment Careers Treatment Achieving one year of recovery Years from first use to last use Has addiction treatment matched an acute care or chronic care style of intervention? The median time was 27 years Years from first treatment attempt to last use The median time was 9 years (range 4 18) Number of treatment episodes The median number of treatment episodes was 3 4 Addiction and Treatment Careers 3. Limitations of an Acute Care Model Years to recovery were significantly longer for: Males People starting use under the age of 21 (particularly those starting under the age of 15) People high in mental distress 5

6 Bill White Atlanta 2009 If we really believed addiction was a chronic disorder Acute care model of addiction treatment We would not: 1. Create expectation that full recovery should be achieved from a single treatment episode Demoralization of clients/families, staff, policy makers, community 2. View prior treatment as indicative of poor prognosis 3. Treat addiction in serial episodes of disconnected TX 4. Relegate aftercare to an afterthought 5. Terminate the service relationship following brief intervention 6. Extrude clients for becoming symptomatic (confirming their diagnosis) Bill White Atlanta 2009 Severing the therapeutic relationship when person becomes symptomatic The Prevailing Acute Care Model Is overly focused on one part of addiction recovery Treatment Crisis stabilization A professional expert drives the process. Services transpire over a short (and ever shorter) period of time. Individual/family/community is given impression at discharge ( graduation ) that recovery is now selfsustainable without ongoing professional assistance (White & McLellan, 2008). 6

7 III. Foundations of Recovery Management 2. Many Paths Into Recovery 1. Defining recovery 2. Growing recognition of the diversity of pathways to and styles of recovery 3. Initiating and sustaining recovery Solo (natural) recovery Peer Assisted Mutual Aid Addiction Recovery Groups Treatment Assisted 1. Efforts to Define Recovery Betty Ford Consensus Panel (2006, 2010) 1. Partial Recovery Depth of Recovery 2. Full Recovery 3. Amplified (Transcendent) Recovery Emerging Definition for Recovery 3. Initiating and Sustaining Recovery Recovery from substance dependence is a voluntarily maintained lifestyle characterized by: o o o Sobriety Personal Health Citizenship Problem severity Problem complexity Addiction Addiction + Mental Illness Addiction + Mental Illness Housing Social Supports Recovery capital Internal and external resources that can be mobilized to initiate and sustain long tern addiction recovery (Granfield and Cloud, 1999). 7

8 Clinical vs. Community Populations Clinical populations: Higher personal vulnerability (e.g., family history, lower age of onset, victimization) Higher severity (acuity & chronicity) Higher rates of co morbidity Greater personal and environmental obstacles to recovery Lower recovery capital (personal assets / family and social supports) 1. Recovery Priming The current AC model fails to attract individuals into recovery Only 10% of those needing treatment received it in 2002 (Substance Abuse and Mental Health Services Administration, 2003) Only 25% will receive such services in their lifetime (Dawson, et al, 2005) IV. Recovery Oriented Systems of Care Why people do not seek treatment Macro system Organizing Philosophy Recovery oriented systems of care (ROSC) are networks of formal and informal services developed and mobilized to support long term recovery for individuals and families impacted by severe substance use disorders. ROSC influences the creation of values and policies in the larger cultural and policy environment that are supportive of these recovery processes. Perception of the Problem Problem isn t that bad V. Recovery Management Microsystem Organizing Philosophy Recovery management (RM) is a philosophy of organizing addiction treatment and recovery support services to enhance: Pre recovery engagement (Recovery Priming) Quality of life Recovery initiation & stabilization Long term recovery maintenance 8

9 Tara Conner Stigma and help seeking Why people do not seek treatment Perception of the Problem Problem isn t that bad Perception of Self Should be able to handle this on my own Perception of Others Fear of stigma and discrimination Perception of Treatment Ineffective, unaffordable, inaccessible 9

10 Recovery Priming The majority of people who do enter treatment do so at late stages of problem severity/complexity and under external coercion (SAMHSA, 2002). The AC model does not voluntarily attract the majority of individuals who meet diagnostic criteria for a substance use disorder. Principle: Earlier the screening, diagnosis & treatment initiation create a better prognosis for long term recovery Recovery Priming: RM Model Strategies Recovery focused anti stigma campaigns Recovery is Everywhere campaign, Ann Arbor, MI Early screening & brief intervention programs Assertive models of community outreach Recovery Priming: RM Strategies Examples from The Healing Place of Wake County Assertive outreach 10

11 Recovery Priming: RM Model Strategies Recovery Priming: RM Model Strategies Non stigmatized service sites Hospitals & health clinics, workplace, schools, community centers Recovery presence in communities Rally for Recovery example Kelly & Westerhoff (2010) study Case studies with substance abuser and person with substance use disorder. Those receiving the abuser paragraph were significantly more likely: To agree that Mr. Williams should be punished and To blame Mr. Williams for his condition and failure to comply with the treatment protocol 2. Recovery Initiation Recovery initiation, engagement and retention Recovery Priming: RM Model Strategies 2. Recovery Initiation Terminology Substance Abuse Access to treatment is compromised by waiting lists (Little Hoover Commission, 2003) Substance Abuser High waiting list dropout rates (25 50%) (Hser, et al, 1998; Donovan et al, 2001). 11

12 2. Recovery Initiation Bill White Atlanta 2009 Dropout rates between initial call and the first treatment session range from 50 64% (Gottheil, Sterling & Weinstein, 1997). Physical and cultural contexts in which people are attempting to initiate recovery More than half of clients admitted to addiction treatment do not successfully complete (OAS/SAMHSA 2005) 2. Recovery Initiation Those least likely to complete are not those who want it the least, but those who need it the most: The most severe & complex problems The least recovery capital The most severely disrupted lives (Stark, 1992; Meier et al, 2006) 2. Recovery Initiation Weak understanding of physical and cultural contexts in which people are attempting to initiate recovery Don Coyhis Bill White Atlanta 2009 AC Model question: How do we get the individual into treatment get them from their world to our world? RM question: How do we nest recovery in the natural environment of this individual? 12

13 Recovery Initiation: RM Model Strategies Streamlined intake Institutional outreach for regular re motivation Radically altered AD polices (White, 2008; White, et al, 2005) Recovery Initiation: RM Model Strategies Motivation for change no longer seen as sole responsibility of individual We ll be here when you re ready Motivation is shared responsibility with the treatment team, family and community institutions (White, Boyle & Loveland, 2003) Motivation is not a pre condition for treatment, but as an outcome of a service process A strong therapeutic relationship can overcome low motivation for treatment and recovery (Ilgen, et al, 2006) Recovery Initiation: RM Model Strategies Lowered thresholds of engagement Bill White Atlanta 2009 Pain (push)/hope (pull) forces Assertive waiting list management Pain based (push force) to hope based (pull force) motivational strategies Appointment prompts & phone follow up of missed appointments 13

14 Bill White Atlanta 2009 Aftercare or continuing care 3. Recovery Durability & Maintenance The majority of people completing addiction treatment resume AOD use in the year following treatment (Wilbourne & Miller, 2002). Of those who consume alcohol and other drugs following discharge from addiction treatment, 80% do so within 90 days of discharge (Hubbard, Flynn, Craddock, & Fletcher, 2001). Aftercare as an Afterthought Recovery Durability & Maintenance Post discharge continuing care can enhance recovery outcomes (Johnson & Herringer, 1993; Godley, et al, 2001; Dennis, et al, 2003) Recovery & re addiction decisions are being made at a time that we have disengaged from their lives But only 1 in 5 (McKay, 2001) to 1 in 10 (OAS, SAMHSA, 2005) adult clients receive such care (McKay, 2001) and only 36% of adolescents receive any continuing care (Godley,et al, 2001) 14

15 Bill White Atlanta 2009 Recovery Durability & Maintenance: RM Strategies Physical and cultural contexts in which people are attempting to initiate recovery Intensity: Ability to individualize frequency and intensity of contact based on clinical data Duration: Continuity of contact over time with a primary recovery support specialist for up to 5 years Location: Community based versus clinic based Staffing: May be provided in a professional or peer based delivery format Assertive linkage: to communities of recovery Recovery Durability & Maintenance: RM Strategies Early re intervention: If & when needed, early reintervention & re linkage to treatment and recovery support groups Continuity of Care: Focus not on service episode but managing the course of the disorder to achieve lasting recovery Technology: Increased use of telephone & Internetbased support services Recovery Durability & Maintenance: RM Strategies Recovery Durability & Maintenance: RM Strategies Post Treatment Monitoring & Support: Provided to all clients not just those who complete Responsibility for contact: Shifts from client to the treatment organization/professional Timing: Capitalizes on critical windows of vulnerability (first days following Tx) and power of sustained monitoring (Recovery Checkups) Examples from The Healing Place of Wake County Telephone recovery support in clients made 2,198 phone calls to 109 clients who were reengaging in recovery following a return to use Letters to inmates in letters were written to incarcerated former/potential clients by current clients 15

16 Recovery Durability & Maintenance: RM Strategies Recovery Durability & Maintenance: RM Strategies Letter writing Recovery Coach Sees possibilities where others see only problems Is personally connected to the communities within the community Can make things happen because they are trusted within these communities Believes the community is a reservoir of untapped hospitality Knows an individual s engagement with the community begins when the guide leaves. (McKnight, 1995) Recovery Durability & Maintenance: RM Strategies Recovery Coach Encourage Self monitoring Recovery Checkups Feedback Stage Appropriate Recovery Education Resource Linkage (Indigenous) Early Re intervention (Treatment) Re engagement and Recovery Priming Following Broken Contact Recovery Durability & Maintenance: RM Strategies Recovery Durability & Maintenance: RM Strategies Recovery Coach Knowledgeable of about indigenous and formal community resources Capable of engaging the difficult to engage person Skilled at leading people into relationship with a recovering community Skilled at sustaining long term recovery support relationships Skilled at organizing resources where none exist Staff & volunteers knowledgeable of multiple pathways/styles of long term recovery, local recovery community resources and Online recovery support meetings and related services (White & Kurtz, 2006) Direct relationship with H & I committees and comparable service structures Recovery coaches provide assertive linkages to support groups and larger communities of recovery 16

17 4. Enhanced Quality of Life Recovery Advocacy Enhancement of quality of personal/family life in long term recovery How do we remove barriers to full citizenship for persons in recovery? Recovery Advocacy 3,500,000 3,000,000 Estimated Annual Alumni Tax Withholdings $3,084,626 $3,277,755 2,500,000 2,000,000 1,500,000 1,000,000 $1,080,651 $816,387 $1,344,915 $1,720,944 $1,890, ,

18 Closing Thoughts 1. ROSC and RM represent not a refinement of modern addiction treatment, but a fundamental redesign of such treatment. 2. It will take years to transform addiction treatment from an AC model of intervention to a RM model of sustained recovery support. Closing Thoughts 3. That process will require replicating across the country what is already underway in the City of Philadelphia: aligning concepts, contexts (infrastructure, policies and system wide relationships) and service practices to support long term recovery. 4. Begin with thinking about how you can incorporate these principles into your practice. Resources Addiction Recovery: A Selected Bibliography with an Emphasis on Professional Publications and Scientific Studies (May 2013) y%20bibliography.pdf 18