Building Recovery Capital: Addiction, Recovery, and Recovery Support Services Among Young Adults

7/30/2019 Building Recovery Capital: Addiction, Recovery, and Recovery Support Services Among Young Adults

1/105

!!!!!!

Title&Below&please&list&the&title&of&this&resource.&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

!Building!Recovery!Capital:!Addiction,!Recovery,!and!Recovery!Support!Services!Among!Young!

Adults!

!

Author&Below&please&list&the&author(s)&of&this&resource."

!John!F.!Kelly,!Ph.D.!

!

Citation&Below&please&cite&this&resource&in&APA&style.&For&guidance&on&citation&format,&please&visit&

http://owl.english.purdue.edu/owl/resource/560/01/&

!Kelly,!John!F.!(2013).!Proceedings!from!the!4th!Annual!Collegiate!Recovery!Conference:! Building"

Recovery"Capital:"Addiction,"Recovery,"and"Recovery"Support"Services"Among"Young"Adults.!Lubbock,!

TX.!

!

Summary&Below&please&provide&a&brief&summary&of&this&resource.&If&an&abstract&is&available,&feel&free&to&copy&and&paste&it&here.&

!

John!F.!Kelly!of!Massachusetts!General!Hospital!and!Harvard!Medical!School!Department!of!Psychiatry!gave!this!presentation!during!the!4th!Annual!Collegiate!Recovery!Conference!held!at!

Texas!Tech!University,!April!35!2013.!


2/105

!!!!!!

12step/community!mutualhelp!participation,!on!which!many!CRCs!are!based,!can!enhance!short!and!longterm!recovery!outcomes!and!simultaneously!reduce!health!care!costs!by!

reducing!reliance!on!professional!services!!

More!research!is!needed!specifically!on!young!adults!regarding!whether!they!may!benefit!more!or!less!from!different!types!of!services!and!supports,!including!optimal!levels!of!mutualhelp!

and!continuing!care!engagement!over!time!after!FSR!!!

!

!

!

!


3/105

BUILDING RECOVERYCAPITAL:

ADDICTION, RECOVERY, AND

RECOVERYSUPPORT SERVICES

AMONGYOUNGADULTS

John F. Kelly, Ph.D.

Massachusetts General HospitalandHarvard Medical School

Department of Psychiatry
http://hms.harvard.edu/


4/105


5/105


6/105


7/105


8/105


9/105

OVERVIEW

A Brief word onterminology

Background andcontext

Recovery andRecovery Capital

and the Importanceof Education as

Recovery Capital

Theories ofRemission and

Recovery

Mutual-helporganization

research, recoverytheory, andimplications for

CRCs


10/105

A WORDON TERMINOLOGYAND STIGMA

SUDs most stigmatized of all social/health problemsMost

Stigmatized

National surveys show stigma one of main reasons people withSUD do not seek specialty care (SAMHSA, 2009)Nationally

WHO examined 18 most stigmatized conditions (eg. criminal,HIV, homeless) across 14 different countries (Room et al 2001)

Drug addiction- #1 - most stigmatizedAlcohol addiction- 4th most stigmatizedInternationally

Ambivalence driven by stigma why only 10% seek specialtycarePoor access


11/105

How we talk and write about these conditions andindividuals suffering them does matter


12/105


13/105

TWOCOMMONLYUSEDTERMS

Referring to someone as

a substance abuser

having a substance use

disorder


14/105

Substance-Related

TermSelf-Regulation(can they controlit?)

Causal Attribution(is it their own

fault?)

Social Distance/Social Danger(arethey dangerous?)

Punishment/

Treatment

3 Subscales: 1. Perpetrator- Punishment2. Social threat3.Victim-treatment


15/105

Mr. Williams is a substance abuser and is attending a treatment programthrough the court. As part of the program Mr. Williams is required to remain

abstinent from alcohol and other drugs. He has been doing extremely well, untilone month ago, when he was found to have two positive urine toxicologyscreens which revealed drug use and a breathalyzer reading which revealedalcohol consumption. Within the past month there was a further urine toxicologyscreen revealing drug use. Mr. Williams has been a substance abuser for thepast six years. He now awaits his appointment with the judge to determine his

status.

Mr. Williams has a substance use disorder and is attending a treatmentprogram through the court. As part of the program Mr. Williams is required toremain abstinent from alcohol and other drugs. He has been doing extremelywell, until one month ago, when he was found to have two positive urine

toxicology screens which revealed drug use and a breathalyzer reading whichrevealed alcohol consumption. Within the past month there was a further urinetoxicology screen revealing drug use. Mr. Williams has had a substance usedisorder for the past six years. He now awaits his appointment with the judgeto determine his status.

Doctoral-level clinicians (n=516) randomized to receive one of two terms.


16/105

14

Figure 1. Subscales comparing the substance abuser and substance use disorder descriptive labels

Kelly, JF, Dow, SJ, Westerhoff, C. Does our choice of substance-related terms influence perceptions of treatmentneed? An empirical investigation with two commonly used terms (2010) Journal of Drug Issues


17/105

IMPLICATIONS

Even without being consciously aware of it, well traineddoctoral level clinicians judged the sameindividualdifferently and more punitively dependingon which termthey were exposed to

Use of the abuser term may activate a negativecognitive schema that perpetuates stigmatizing attitudes these could have broad stroke societal ramificationsfor treatment/funding

Individuals with eating related problems are uniformlydescribed as having an eating disorder NOT as foodabusers

Referring to individuals as suffering from substance usedisorders is likely to diminish stigma and may enhancetreatment and recovery


18/105

OVERVIEW





Recovery Capital


Recovery


research, recoverytheory, and

implications forCRCs


19/105

DRUGAND ALCOHOLIMPACT

#1 public health problem (Institute for HealthPolicy, 2001; CASA, 2011)

Of all disease, disability, and deaths due to allpsych conditions, AUD alone = 36%

Public health

$500 billion in US each year (lost productivity,criminal justice, medical costs)

Excessive alcohol consumption costs society $2per drink (CDC, 2011)

Financial

SUD leading cause of mortality - alcohol leadingrisk factor worldwide among males 15-59

Opiate overdose leading cause of accidentaldeath nationwideMortality

Onset of long-term problems occur duringadolescence/young adulthood

90% adults with dependence start using before age18

50% of adults start using before age 15

Prevention


20/105

Comparison of the magnitude of the ten leading diseases and injuries and the tenleading risk factors based on the percentage of global deaths and the percentage ofglobal DALYs, 2010

Figure shows 25 total diseases, injuries, and risk factors because some of the largest contributors to disability-adjusted life years (DALYs) were not in the top ten for deaths, and vice versa.

DALYs=disability-adjusted life years. IHD=Ischaemic heart disease. LRI=Lower respiratory infections. COPD=chronic obstructive pulmonary disease. HAP=household air pollution from solid fuels.BMI=body mass index. FPG=fasting plasma glucose. PM2.5Amb=ambient particular matter pollution. *Tobacco smoking, including second-hand smoke. (t)Physical inactivity and low physicalactivity


21/105

ECONOMICCOSTSTOSOCIETY

Bouchery et al. (2011), CDC (2012), US Department of Justice (2011)

$0

$50

$100

$150

$200

$250

$300

$350

$400

$450

Alcohol and Illicitdrugs

Diabetes Obesity Smoking Heart disease

Economic cost (in billions)


22/105

% USINGPRIORTOAGE 15

0%

5%

10%

15%

20%

25%

30%

35%

1934-1944 1945-1955 1956-1960 1961-1965 1966-1970 1971-1975 1976-1980 1981-1985 1986-1990

%u

sing Alcohol use

Marijuana

Cocaine

Hallucinogens

Adapted from: Johnson and Gerstein (1998) Am Jnl Public Health, 88, 1, 27-33


23/105

PREVENTION

% MEETING DSM III R LIFETIME ALCOHOL


24/105

% MEETING DSM-III-R LIFETIMEALCOHOLDEPENDENCECRITERIA

Adapted from: Rice, J. P., Neuman, R. J., Saccone, N. L., Corbett, J., Rochberg, N., Hesselbrock, V., & ... Reich, T. (2003).Alcoholism: Clinical And Experimental Research, 27(1), 93-99.

0%

5%

10%

15%

20%

25%

30%

35%

1910-1929 1930-1939 1940-1949 1950-1959 1960-1979

Male (n=509)

Female (n=545)

Birth Cohort


25/105

SUBSTANCE USE DISORDERS (SUD) INTHE PAST

YEAR AMONG PERSONS AGE 12 OR OLDER


26/105

PREVALENCEOF DSM-IV ALCOHOL DEPENDENCE

ACROSSTHE LIFESPAN (NESARC)

Source: Grant, Dawson et al, 2004


27/105

SUBSTANCE USEAND PROBLEM ONSETAND OFFSET

NSDUH and Dennis & Scott

0

10

20

30

40

50

60

70

80

90

100

12-13

14-15

16-17

18-20

21-29

30-34

35-49

50-64

65+

No Alcohol or Drug Use

Light Alcohol Use Only

Any Infrequent Drug Use

Regular AOD Use

Abuse

Dependence

National Survey on Drug Use and Health (NSDUH) Age Groups

Severity Category


28/105

SERIOUS PSYCHOLOGICAL DISTRESS(NSDUH, 2007)


29/105

10

14

25 25

18

13

10

87

65

0

5

10

15

20

25

30

15-17 18-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64

age

% Residential Change

GENERAL MOBILITY: 2011-2012 U.S. CENSUS


30/105

WHYDOES SUD ONSETINYOUNGPEOPLE?DEVELOPMENTAL CONSIDERATIONS & RISKS

Desire forbidden (fermented) fruit associated with being grown up

New social freedoms with age of majority (i.e., 18 yrs = right to vote,serve on jury/military/marry) independent living (e.g., college),employment/$$$

Exhilarating abrupt cognitive shift in perceived control and self-determination, but objective psychobiological reality =continues to begradual developmental changes - impulse control, self-regulation, riskappraisal (Giedd et al, 1999).

Lower sensitivity to (psychomotor) negative impairments than adults(BUT, more sensitive to memory impairments)

So, desire for forbidden fruit & self-expression coupled withincongruency between subjective perceptions and objective realitycreates new risks & challenges particularly regarding alcohol/drugs


31/105

REGIONAL VARIATION IN RATES OF PROBLEM USE

29

Figure 5.3 Alcohol Dependence or Abuse in Past Year among PersonsAged 18 to 25, by State: Percentages, Annual Averages Based on 2008and 2009 NSDUHs

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH, 2008 and 2009


32/105

REGIONAL VARIATION IN RATES OF PROBLEM USE

30

Figure 2.3 Illicit Drug Use in Past Month among Persons Aged 18 to 25,by State: Percentages, Annual Averages Based on 2008 and 2009NSDUHs

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH, 2008 and 2009.


33/105

COLLEGE YOUTH NATIONAL PREVALENCEOFSUBSTANCE USE

Full-time students: 49% engage in hazardoususe & 25% meet criteria for SUD (8.5% ingeneral population)

Consequences of substance misuse in

students: alcohol-related deaths/injuries, arrests, unplanned sex, sexualviolence, fights, poorer health, academic problems

College campus considered a pro-drug cultureand substance use is viewed as a harmlessrite of passage

37% of college students fear seeking helpbecause of social stigma, and of those whomeet the SUD criteria only 6% sought help(10% in general populations)

(Bell et al, 2009)


34/105

Developmental Milestones: SUD in

emerging adults by College Enrollment

NSDUH: Heavy Alcohol Use among Adults Aged 18 to 22, by College Enrollment: 2002-2005


35/105


36/105

HELP-SEEKINGBEHAVIORBYCURRENTCOLLEGEENROLLMENTSTATUS

Research Question: What is the utilization andperceived need for alcohol treatment servicesamong college-age young adults according to theireducational status?

Sample: 11,337 young adults (18-22 yrs) who wereeither full-time college students, part-time collegestudents, non-college students or nonstudents in

the United States

Study Design: Cross-sectional data from theNational Survey on Drug Use and Health (2002)

Wu L, Pilowsky DJ, Schlenger WE & Hasin D, (2007), Alcohol use disorders and the use oftreatment services among college-age adults Psychiatr Serv, 58(2): 192-200.


37/105

LIKELIHOODOFTREATMENTUTILIZATIONAMONGYOUNGADULTSWHOMETCRITERIAFOR PPY AUD

Full-Time College

Part-Time College

Noncollege

Nonstudent

Odds of Treatment Utilization

Adjusted Odds Ratio

1.0 1.5 2.0 2.5 3.0

1.67

2.87

*


38/105

OVERVIEW





Recovery Capital


Recovery


research, recoverytheory, and

implications forCRCs


39/105

Recovery capital (RC) is definedas the breadth and depth of

internal and external resourcesthat can be drawn upon to initiateand sustain recovery (Granfield &

Cloud, 1999; Cloud & Granfield,2004).

A


40/105

Substance-related

Problems(physical and mental

health, housing, socialrelations, education and

employment, meaning and

purpose in life)

Addiction Severity

Recovery Capital(physical and mental

health, housing, social

relations, education andemployment, meaning and

purpose in life)

Addiction Remission

A

B

R CO CO S E C O B S R CO


41/105

RECOVERYCONTEXTS: EDUCATION BASED RECOVERYSUPPORTS

College education trumped

money and social prestigeas the pathway to healthand happiness (Vaillant,2011)

Despite big differences

between core city sample andHarvard sample in parentalsocial class, college-testedintelligence, current incomeand job status, health declineof inner-city men who

obtained a collegeeducation was same asHarvard sample

Education representsimportant recovery capital

for young people (Vaillant & Mukamal, 2001, Am. Jnl. Of


42/105

What are Recovery support services?

Why are they so important?

Residential recovery homes (e.g., OxfordHouses)

Recovery community centers (RCCs)

Peer-based Recovery support Education-based recovery support: high

school and college based recovery support for

young people Mutual-help organizations, like AA, NA, and

SMART Recovery


43/105

AddictionOnset

HelpSeeking

Full SustainedRemission (1

year

abstinent)

Relapse Riskdrops below

15%

4-5 years 8 years 5 years

Self-

initiated

cessation

attempts

4-5

Treatment

episodes/mutual-

help

Continuing

care/

mutual-

help

Educational Recovery Capital (and CRCs) important given the

typical Clinical Course for Substance Dependence and Recovery

Wang, P. S., Berglund, P., Olfson, M., Pincus, H. A., Wells, K. B., & Kessler, R. C. (2005).

Dennis, M. L., Scott, C. K., Funk, R., & Foss, M. A. (2005).De Soto, C.B., ODonnell, W.E., & De Soto, J.L. (1989).


44/105

Despite education important to longterm health/well-being, college

environment recovery unfriendly -activities organized aroundalcohol/parties; recovery statussecret

Collegiate Recovery Communities(CRCs) provide safe place; sobriety-friendly network

Founding college programs:- Augsburg College

- Texas Tech University

- Rutgers (1st to offer on-campus residence hall forrecovering students)

Schools provide academic services

and assistance with recovery andcontinuing care, but they are nottreatment centers

No experimental/comparativeeffectiveness trials to estimateextent and nature of benefits

TEXAS TECH UNIVERSITY: SINGLE GROUP PRE


45/105

TEXAS TECH UNIVERSITY: SINGLEGROUP PRE-POST DESIGN

To enter the CRC, students need to have 1 year of recovery,

attend at least 1 12-step on campus meeting per week, andsucceed in their classes

evaluation of the program: 2004-2005, N=82, (18-53 yrs old)

relapse rate within a semester was 4.4%; most maintainedhigh GPA

Source: Cleveland et al. (2007)

AUGSBURG COLLEGE


46/105

AUGSBURG COLLEGESTEPUPPROGRAM

Support groups and sobriety-specific houses Outcomes Annual

avg relapserateacross13 yrs = 13%,

Down to abou7% in recent

R R H


47/105

RUTGERS RECOVERY HOUSEDATA2008-2011

Source: Laitman & McLaughlin (2011)

Annualavg relapserateacross13 yrs = 6%


48/105

DATAFROMRECOVERYHIGHSCHOOLS


49/105

RECOVERY-RELATEDOUTCOMESAMONG 72RECOVERYHIGHSCHOOLGRADUATES

Surveys sent to Serenity High School alumnigraduating between 2000-2010

39% reported no drug/alcohol use in last 30 days(state of the art CYT study=25%)

More than 90% of participants reported enrolling incollege

Collegiate recovery environment may normalizeand destigmatize addiction/recovery increasing thechances of ongoing recovery or re-engagementwith recovery

Lanham CC & Tirado JA, (2011). Lessons in sobriety: an exploratory study of graduate outcomes at a recovery high school. Journalof Groups in Addiction and Recovery, 6:245-263.


50/105

OVERVIEW


Background and

context



Recovery Capital


Recovery


research, recovery

theory, andimplications for

CRCs


51/105

HOWDO CRCSAND RECOVERYSUPPORTSERVICESHELP? THEORIESOF REMISSIONAND RECOVERY

Studies of treatment are often theory-based (e.g,Longabaugh and Morgenstern, 2002; Moos, 2007)

However, studies of SUD remission and recoveryare very seldom theory-based

But, there are empirically supported theories thathelp explain the onset of substance use and SUD

These same theories may be useful in helpingexplain SUD remission and recovery


52/105

The social contexts that underlie the

initiation and maintenance of substance

misuse may hold within them thepotential for resolution of the problems

they create

(Moos, 2011)

Parallels in the onset and offset of


53/105

People want to use

substances for 4 main

reasons (NIDA, 2005):To feel good

To feel better

To do better

Because others are

doing it

Parallels in the onset and offset ofSUD

Parallels in the onset and offset of


54/105

People want to use

substances for 4 main

reasons (NIDA, 2005):

People want to stop using

substances and recover for

the same 4 main reasons:To feel good To feel good

To feel better To feel better

To do better To do better

Because others are

doing it

Because others are

doing it

Parallels in the onset and offset ofSUD


55/105

Theory Key process mechanisms for

Substance use Recovery

SocialControl Lack of strong bonds with family,friends, work, religion, other aspects

traditional society

Goal-direction, structure and monitoring,shaping behavior to adaptive social bonds

Social

Learning

Modeling and observation and

imitation of substance use, social

reinforcement for and expectations

of positive consequences from use;

positive norms for use

Social network composed of individuals

who espouse abstinence, reinforce negative

expectations about effects of substances,

provide models of effective sober living

Stress and

coping

life stressors (e.g.,

social/work/financial problems,

phys/sex abuse) lead to substance

use especially those lacking coping

and avoid problems; substance use

form of avoidance coping, self-

medication

Effective coping enhances self-confidence

and self-esteem

Behavioral

economics

Lack of alternative rewards provided

by activities other than substance

use

Effective access to alternative, competing,

rewards through involvement in

educational, work, religious,

social/recreational pursuits

Source: Moos, RH (2011) Processes that promote recovery from addictive disorders.


56/105

COLLEGIATERECOVERYCOMMUNITIESTheory Key process mechanisms for

Substance use RecoverySocial

Control

Lack of strong bonds with family,

friends, work, religion, other aspects

traditional society

Goal-direction, structure and monitoring,

shaping behavior to adaptive social bonds

Social

Learning




of positive consequences from use;positive norms for use





Stress and

coping






form of avoidance coping, self-medication


and self-esteem

Behavioral

economics



use





Source: Moos, RH (2011) Processes the promote recovery from addictive disorders.


57/105

ADDICTION RECOVERY MUTUALAIDORGANIZATIONSTheory Key process mechanisms for

Substance use RecoverySocial

Control



traditional society



Social

Learning









Stress and

coping








and self-esteem

Behavioral

economics



use






SOCIALSUPPORTINCOLLEGIATERECOVERY


58/105

COMMUNITIESMAYBEANALOGOUSTOTHEMEDIATINGEFFECTSSEENIN 12-STEPRESEARCH

Humphreys K, Mankowski ES, Moos RH & Finney JW (1999). The effect of self-help

groups on substance abuse?. Ann Behav Med 21(1):54-60


59/105

AAATTENDANCEANDTHE % CHANGEINBOTHPRO-ABSTINENTANDPRO-DRINKINGNETWORKTIESFROMTREATMENTINTAKETOTHE 9-M

(OP SAMPLE)

Source: Kelly et al, 2011, Drug and Alcohol Dependence


60/105

AAATTENDANCEANDTHE % CHANGEINBOTHPRO-ABSTINENTANDPRO-DRINKINGNETWORKTIESFROMTREATMENTINTAKETOTHE 9-M

(AC SAMPLE)

Source: Kelly et al, 2011, Drug and Alcohol Dependence


61/105

IS THE SOCIAL SUPPORT MODEL APPLICABLE


62/105

ISTHESOCIALSUPPORTMODELAPPLICABLETOCOLLEGIATERECOVERYCOMMUNITIES?

Sample: 84 students participating in acollegiate recovery community (4 sites)

Study Design: cross-sectional survey

CastiraghiAM (2012). Students perceptions of social support and recovery:

The social support model used in replicating collegiate recovery communities.M.S. Thesis, Texas Tech University


63/105


64/105

CASIRAGHITHESISSOCIALSUPPORTSUBGROUPS

Appraisal: emotional support consisting of caring,empathy, trust and love; having someone readilyavailable to talk to about your problems

Belonging: companionship; establishment of mutually

valuable relationships through participation in socialactivities

Tangible: instrumental support consisting of materialitems (e.g. food, clothing, furniture, financial help, orspecific behavioral aid such as transportation)

Validation: expression that optimistically influences apersons sense of self worth; confirmation of theappropriateness or normalcy of a persons behaviorthrough social comparison


65/105

ISSOCIALSUPPORTASSOCIATEDWITHRECOVERYQUALITYINCOLLEGIATERECOVERYCOMMUNITIES?

Sub-groups of social support (e.g. appraisal, belonging,tangible, validation)werent independently predictive ofrecovery quality

Overall social support was directly associated withrecovery quality

Younger students perceived greater amounts of

recovery

Conclusion: A holistic approach to social supportinvolving all 4 elements of support may benefitrecovering students

CastiraghiAM (2012). Students perceptions of social support and recovery: The social support model used in replicating collegiate recoverycommunities. M.S. Thesis, Texas Tech University

THEORYBASEDCOMPARISONBETWEENCOLLEGEAS


66/105

USUAL VS. CRC FORRECOVERINGSTUDENTSCollege-as-usual CRC

Socialcontrol

Maladaptive social bonds;hazardous/harmful substanceuse; antisocial behavior; let itall hang out

Adaptive social bonds; pro-socialnorms; monitoring/supervision;emphasis on education andachievement

Social

learning

Norm is party; alc/drug use

modeled and reinforced;stigma associated with help-seeking

Norm is sobriety and recovery;

abstinence reinforced; stigma/shamereduced with validation and praise forrecovery status; help-seeking stronglyencouraged

Stress andcoping

Substance use is predominantcoping strategy; substance

induced confidence; avoidancecoping

Community predominant copingstrategy; genuine confidence; approach

coping; focus on positive experienceand academic achievement

Behavioraleconomic

Substance use predominantreinforcer for commiseration orcelebration

Effective provision of alternativerewarding behaviors; successexperience; validation


67/105

OVERVIEW


Background and

context



Recovery Capital


Recovery


research, recovery

theory, andimplications for

CRCs


68/105

CRCs and building Social Recovery


69/105

CRCs and building Social Recovery

Capital

Most CRCs are based on 12-step principlesand require 12-step attendance

Does 12-step participation help young people?How much participation should berecommended?

How can CRCs benefit from the knowledgegained from 12-step research?


70/105

Young Adults and Mutual-help

0rganization Participation

Youth Barriers to 12-step Mutual help


71/105

Youth Barriers to 12-step Mutual help

participation

Only about 14% under the age of 30 in AA andNA

May create barriers to identification/sense of

belonging: Addiction specific (young adults more polydrug

use; less addiction severity/medical sequelae)

Different life stage/life context differences: less

likely to be married/have children Spiritual emphasis less appealing


72/105

Adolescent 12-step Participation across 8


73/105

Adolescent 12 step Participation across 8

Years into emerging adulthood

Participants (N=166; 40% female; M age 16;75% Caucasian) consecutive admits toadolescent 12-step oriented, inpatient, SUDprograms in San Diego (M stay = 4 wks)

Followed at 6m and 1, 2, 4, 6, and 8yrs (follow-up rates > 84%)

Neither demographic nor tx/clinical vars foundassociated with follow-up (ps>.27).

Source: Kelly, Brown, Abrantes et al, 2008; Alcoholism: Clinical Experimental Research

Results: Rates of Attendance


74/105

Results: Rates of Attendance

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-6m 6m-1yr 1-2yr 2-4yr 4-6yr 6-8yr

Follow-Up

%A

ttending

AA/NA

Any

Monthly

Weekly

Any, Monthy, and Weekly AA/NA Attendance across 8 Years

Following Inpatient Treatment

Source: Kelly, J.F., Brown, S. A., Abrantes, A., Kahler, C. H., & Myers, M. (2008) Social Recovery Model: An 8-

year Investigation of adolescent 12-step group participation following inpatient treatment. Alcoholism:Clinical and Experimental Research.

Percent of Youth in Each Trajectory Outcome Group attending AA/NA at least Weekly


75/105

0

10

20

30

40

50

60

70

80

90

100

6m 12m 24m 48m 72m 96m

%At

tendingAA/NAweekly

Time

Percent of Youth in Each Trajectory Outcome Group attending AA/NA at least Weeklyacross 8 Years

Abstainers

Infrequent User

worse with time

Frequent User

Lagged GEE Model of Youth Treatment Outcome in relation


76/105

gg

to AA/NA attendance over 8 Years

Parameter Estimate Standard Error 95% Confidence

Limits

Z P

Intercept 37.3071 6.9601 23.6656 50.9486 5.36


77/105

75

Kelly JF, Brown SA, Abrantes, A. et al. Social Recovery Model: An 8-Year Investigation of Youth Treatment

Outcome in Relation to 12-step Group Involvement.Alcoholism: Clinical and Experimental Research, 2008, 32, 8

1468-1478.


78/105


79/105

Results: Significant independent effects for attendance on abstinence from all drugs and

reduced heavy alcohol use, and stronger effects for 12-step involvement (lagged, controlled,


80/105

prospective models)

Relation between Age Composition of Attended Meetings and

f


81/105

All teensMostly teensEven mixMostly adultsAll adults

100

95

90

85

80

75

70

65

60

55

50

Days Abstinent (3m)

Days Abstinent (6m)

Percent Days Abstinent for Adolescents

Kelly, Myers & Brown, (2005)Journal of Child and Adolescent Substance Abuse


82/105

I li i f CRC ?


83/105

Implications for CRCs?

12-step participation, particularly active involvement, appears to help young adultsmaintain recovery across time

Homogeneity in terms of young adults may be helpful in terms of engaging youngpeople with CRCs, but being too exclusive on age may limit the benefits that eithergreater life experience or longer recovery confers

Having a mix of age (life-experience) and different lengths of recovery may beoptimally therapeutic

There are observed relationships between 3x/week attendance and completeabstinence early post treatment; recommended or required attendance frequencyafter achieving full sustained remission is unclear

However, given that the risk of relapse after full sustained remission doesnt dropbelow 15% until 5 yrs, regular, weekly or twice weekly attendance or more (especially in the first year re-enrolling in college) may provide continued recovery-specific support and help buffer stress of adapting to high risk environment


84/105

CRCs: Cost-efficient Model of Recovery Support through


85/105

facilitating 12-step involvement?


86/105


87/105

HEALTH CARECOSTOFFSET

CBT VS 12 STEP RESIDENTIAL TREATMENT


88/105

$12,129

$7,400

$5,735

$2,440

$17,864

$9,840

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000$14,000

$16,000

$18,000

$20,000

CBT TSF

Year 1

Year 2

Total

CBT VS 12-STEP RESIDENTIAL TREATMENT

Compared to CBT-

treated patients, 12-step treated patients

more likely to be in

recovery, at a $8,000

lower cost per pt

over 2 yrs ($15M

total savings)


89/105

The first study to examine how 12-Step participation affectsmedical costs in adolescents with SUD

4 intensive outpatient programs

N = 403 adolescents, age 13-18

66% male; mean age 16.1; 49% White

Comorbid ADHD: 17%, depression: 36%

Follow-up: 6 months, 1, 3, 5, and 7 years

Difference-in-difference model was used

Source: Mundt, Parthasarathy, Chi, Sterling, Campbell (2012)


90/105

Patients attending 12-step meetings had

better substance use outcomes

4.7% decrease in medical costs with each

additional 12-step meeting attended =

$145 annual savings per 12-step

meetings attended

Source: Mundt, Parthasarathy, Chi, Sterling, Campbell (2012)

How might MHOs like AA reduce relapse risk and aid the recovery process?Do these mechanisms differ for different people?


91/105

89

Social

Psych

Bio-Neuro

RELAPSE

Cue Induced

Stress Induced

Drug Induced

Do these mechanisms differ for different people?

MHO

Path diagram of the lagged mediational model for inpatient vs. outpatient and men vs. women.


92/105

90

(9-mo) Self-efficacyNegative Affect

Baseline (BL) CovariatesAge

Race

Marital status

Employment status

Prior alcohol treatment

MATCH treatment group

MATCH study site

Alcohol outcomes (PDA/DDD)

(15-mo) Alcohol Outcomes(PDA or DDD)

(3-mo) AA Attendance

(BL) Self-efficacyNegative Affect

(9-mo) Self-efficacyPositive Social

(BL) Self-efficacyPositive Social

(9-mo) Spiritual/ReligiousPractices

(BL) Spiritual/ReligiousPractices

(9-mo) Depression(BL) Depression

(9-mo) Social Networkpro-abstinence

(BL) Social Networkpro-abstinence

(9-mo) Social Networkpro-drinking

(BL) Social Networkpro-drinking

DOMOREANDLESSSEVERELYALCOHOLDEPENDENTINDIVIDUALSBENEFITFROM AA INTHESAMEORDIFFERENTWAYS?

ff t f AA


93/105

Self-efficacy

(NA)

5%

Depression

3%

Spirit/Relig

23%

Self-efficacy

(Soc)

34%

SocNet: pro-

abst.

16%

SocNet: pro-drk.

24%

Aftercare (PDA)

Self-efficacy

(NA)

1%

Depression

2% Spirit/Relig

6%

Self-efficacy(Soc)

27%

SocNet: pro-

abst.

31%

SocNet: pro-drk.33%

Outpatient (PDA)

Self-efficacy

(NA)

20%

Depression

11%

Spirit/Relig

21%

Self-efficacy

(Soc)

21%

SocNet:

pro-abst.

11%

SocNet: pro-drk.16%

Aftercare (DDD)

Self-efficacy

(NA)

1%

Depression

5%

Spirit/Relig

9%

Self-efficacy

(Soc)

39%

SocNet: pro-

abst.

17%

SocNet: pro-drk.

29%

Outpatient (DDD)

91

effect of AA onalcohol use for

AC wasexplained bysocial factors

but also by S/Rand throughnegative affect(DDD only)

Majority ofeffect of AA onalcohol use forOP wasexplained bysocial factors

Source: Kelly, Hoeppner, Stout, Pagano (2012) , Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous:A multiple mediator analysis.Addiction 107(2):289-99

DOMENANDWOMENBENEFITFROM AA INTHESAMEWAYS?PERCENTAGEOFEFFECTOF AAATTENDANCEONOUTCOMES (PDA; DDD) FORMENANDWOMENACCOUNTED


94/105

FORBYTHESIXMEDIATORS

92

MODERATED-MECHANISMS: AA EFFECTS


95/105

MODERATED MECHANISMS: AA EFFECTSMODERATEDBY SEVERITYAND GENDER

CONCLUSIONS

Recovery benefits derived from AA differ in nature and magnitude betweenmore severely alcohol involved/impaired and less severely alcoholinvolved/impaired; and between men and women

These differences reflect differing needs based on recovery challengesrelated to differing symptom profiles, degree of subjective suffering andperceived severity/threat, recovery challenges, and gender-based socialroles & drinking contexts

Similar to psychotherapy literature (Bohart & Tollman, 1999) rather thanthinking about how AA or similar organizations work, better to think howindividuals use or make these organizations work for them to meettheir most urgent needs at any given phase of recovery

SO, COLLEGIATERECOVERYPARTICIPANTSMAYUSEDIFFERENT ASPECTS DIFFERENTLY


96/105

DIFFERENTASPECTSDIFFERENTLYTheory Key process mechanisms for

Substance use Recovery

Social

Control



traditional society



Social

Learning









Stress and

coping








and self-esteem

Behavioral

economics



use






HOW MIGHTTHESEFINDINGSINFORMCOLLEGIATE


97/105

RECOVERY RELAPSEPREVENTIONEFFORTS?

12-step basis and related TSF focus in CRCs may prove to be acost-efficient method for maintaining recovery over time

Perhaps the social relapse risks - although generally a morepotent precursor among youth than adults - is relatively more

important for males than females, whereas negative affect maybe a more important factor for females

More research is needed in this regard

However, in general, sensitivity to mood regulation needs amongwomen may reduce relapse risk and enhance quality of life;sensitivity to social risk needs among young men may boostsocial self-efficacy and reduce relapse risk

TSF Delivery ModesT

S

O

T


98/105

TSF Delivery ModesSF

T

H

Component of a treatment package

(e.g., an additional group)Stand alone

Independent therapy

Integrated into an existing

therapy

As Modular appendagelinkage component

e.g., Timko et al, (2006; 2007;

2011); Kahler et al, (2005);

Sisson and Mallams, (1981)

e.g., Kaskutas et al, (2009)e.g., Walitzer et al, (2008);

Litt et al, (2009)

e.g., Project MATCH

Research Group (1997); Litt

et al, (2009)

Research on


99/105

alternativeMHOs

scarce

It is likely that many of theti i di t i 12 t


100/105

active ingredients in 12-stepMHOs are also active in

other MHOs and maymobilize the same kinds of

intrinsic processes as do 12-step

ARE SOCIAL NETWORKS A CAUSAL MECHANISM IN


101/105

ARESOCIALNETWORKSACAUSALMECHANISMINRECOVERYPATHWAYS?

Employed propensity score stratification (e.g., Dehejia and Wahba,2002), designed to minimize impact of selection biases due to

measured covariates.

No statistical adjustment can completely eliminate chance that an

unknown factor is responsible for improvement/deterioration that

appears to be correlated with a change in social networks. However,propensity stratification methods represent the state of the

statistical art in this domain (Rubin, 2006), and have been rarely

utilized in addiction research

Source: Stout, Kelly, Magill, Pagano (2012) Journal of Studies on Alcohol and Drugs

ARE SOCIAL NETWORKS A CAUSAL MECHANISM IN


102/105

ARESOCIALNETWORKSACAUSALMECHANISMINRECOVERYPATHWAYS?

Predictor variables selected based on prior research or theoryindicative of an association between each proposed predictorvariable and at least one of the social network measures

23 baseline and 3m (AA only) predictors of social networks were

used in propensity analysis

If significant effect of the variable of interest after propensity scoreadjustment then there is stronger evidence that this plays a causal

role on the outcome; if not, then assumed that the variables

relationship to outcome is accounted for by other variables and is notcausal

100


103/105

101

Pro-drinkers and pro-abstainer networkvariables were found toexert enduring influenceacross a 3yr period over

and above that of otherinfluential socialorganizations like AA

OVERVIEW


104/105

OVERVIEW

A Brief word on

terminology

Background and

context

Recovery andRecovery Capitaland the Importance

of Education asRecovery Capital


Recovery


research, recovery

theory, andimplications forCRCs

SUMMARY


105/105

SUMMARY The way we talk and write about individuals with substance-related problems may

trigger certain cognitive schemas that can have unwanted consequencesas withthe eating disorders field, use of substance use disorder terminology may helpreduce stigma and increase treatment access/engagement

Recovery capital is a key component of the recovery construct and education isassociated with building self-esteem and hope for a better future that may have

physicalas well as psychological and emotional health benefits (i.e., holistic)

CRCs provide young adults a de-stigmatizing and self-actualizing recoverynormative environment that promotes and provides adaptive social bonds, copingskills, and competing rewards as they attempt to achieve major milestones

12-step/community mutual-help participation, on which many CRCs are based, can

enhance short and long-term recovery outcomes and simultaneously reduce healthcare costs by reducing reliance on professional services

More research is needed specifically on young adults regarding whether they may

Documents

Building Recovery Capital: Addiction, Recovery, and Recovery Support Services Among Young Adults