The Intersection of Prevention and Recovery: Community

1. The Intersection of Prevention and Recovery: Community ADAA Management Conference 2009 Virgil Boysaw and Sue Jenkins, Presenters

2. Objectives • Describe elements of Recovery Oriented Systems of Care • Identify the conceptual foundation for prevention services in a ROSC system • Describe similarities and opportunities for partnership in SPF and ROSC processes • Identify cross-functional skills that support partnerships between prevention and treatment professionals

3. How does a Recovery Oriented System of Care change the delivery of addiction treatment services?

4. Alcohol and Drug Use in the Community • Continuum from non-use to regular heavy use • Diagnostic classifications • Substance Abuse and Substance Dependence • Wider span of problematic use is not captured in diagnostic classifications

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

6. Community vs. Clinical Populations • Marked differences • Greater personal vulnerability • Family history of substance use disorders • Child maltreatment • Early puberty • Early age of onset of AOD use • Personality disorders during early adolescence • Substance using peers • Greater cumulative lifetime adversity

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

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

9. Recovery Rates • Community studies of recovery from alcohol dependence report long-term recovery rates approaching or exceeding 50%.

10. Past Models of Addiction • All based on acute models of care

11. Acute Care Model of Treatment Services are delivered in a uniform series of encapsulated activities • screening, • admission, • a single point-in-time assessment, • a short course of minimally individualized treatment, • Discharge and brief “aftercare”, followed by termination of the service relationship.

12. Acute Care Model • Focused on symptom elimination for a single primary problem • A professional expert directs and dominates decision-making throughout this process. • Services transpire over a short period of time. • pre-arranged, time-limited insurance payment designed specifically for addiction disorders and “carved out” from general medical insurance

13. Acute Care Model • At discharge, “cure has occurred:” long-term recovery is then viewed as self-sustainable without on-going professional assistance. • Evaluation of success occurs at a single point-in-time follow-up, typically just months after treatment. • Post-treatment relapse is viewed as the failure (non-compliance) of the individual, rather than potential flaws in the design of the treatment protocol.

14. Evidence from Acute Care Models • Low Treatment Compliance • 50% of outpatients drop out of treatment within one month • 40% of court-ordered patients do not complete treatment • Relapse Rates are High • About 60% use drugs within six months following treatment discharge (Hubbard, Flynn, Craddock, & Fletcher, 2001); (Watkins, Pincus, Tanielian, & Lloyd, 2003)

15. Addiction/Chronic IllnessCompliance Rate Relapse Rate (O'Brien & McLellan, 1996)

16. Recovery-Oriented System Goals • Intervene earlier in the progression of the disease • Improve treatment outcomes • Support sustained recovery

17. Acute Care Model → Recovery Oriented System of Care Abstinence → Wellness Recovery Support Services Sober or supported housing Transportation Childcare Legal services Educational/vocational supports • Outreach • Engagement and intervention services • Recovery guiding or coaching • Post treatment monitoring and support

18. Recovery Oriented System of Care • Improved Quality of Treatment • Emphasis on outreach, access and engagement • Evidence based practices • Individualized treatment, more choices • Increased family involvement • Integration with physical health and mental health services • Change in nature of helping relationship

19. Recovery Oriented System of Care • Active Relationship with Community “The community, not treatment, is the agent of recovery” • Advocacy • Confront AOD promotional forces in the local community • Promote pro-recovery policies • Recovery resource development • Recovery community centers • Alternative peer recovery support groups • Stigma reduction efforts

20. How does the Strategic Prevention Framework change the provision of prevention services?

21. Strategic Prevention Framework • Create communities in which people have a quality life including • healthy environments at work and in school; • supportive communities and neighborhoods; • connection to families and friends and • an environment which is free of alcohol, tobacco, and other drugs and crime free (SAMHSA/CSAP, 2006)

22. Strategic Prevention Framework • Prior to SPF, prevention was defined as an intervention in which specific groups, families or individuals were targeted (i.e. selected or indicated) • The goal of this approach was to build individual protective factors while reducing risk factors (NIDA 1997, 2003)

23. S PF Goals • Bring the power of individual citizens and institutions together • Create a comprehensive plan that everyone has a stake in and owns • Foster continued systems approaches as the community experiences the outcome of its investments • Hold community institutions responsible (CSAP, 2006)

24. SPF Measures • By consumption amount, consequences associated with consumption and success in preventing the problems associated with use • Across the lifespan (not just with youth) • Based on evidence-based research and empirical data • As outcomes at the population level (not just program level)

25. Unified Model • Prevention can be enhanced to address any and all factors that lead to use or lessening of wellness or loss of sustained recovery by adapting current prevention strategies to a Recovery and Wellness model (grounded in a Chronic Care model) (Hogan, Gabrielson, Luna, & Grothaus, 2003)

26. Recovery and Wellness Model • Focus is on building resiliency • The strength individuals and communities attain by reducing risk factors and increasing protective factors • Rather than addressing a single problem or condition, it simultaneously considers a potential wide-ranging set of ATOD-involved problems

27. Recovery and Wellness Model • Rather than focusing on individuals at risk, it studies the entire community • Rather than basing prevention strategies on single assumptions about deterministic behavior, it employs interventions that alter the social, cultural, economic and physical environment in such a way as to promote shifts away from conditions that favor the occurrence of ATOD- involved problems. (Holder, 1998)

28. Reference Special Report A Unified Vision for the Prevention and Management of Substance Use Disorders: Building Resiliency, Wellness and Recovery – A Shift from an Acute Care to Sustained Care Recovery Management Model Complied by: Michael T. Flaherty, PhD Institute for Research, Education and training in Addictions (IRETA)