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

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Building!Recovery!Capital:!Addiction,!Recovery,!and!Recovery!Support!Services!Among!Young! Adults!
! Author&
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John!F.!Kelly,!Ph.D.!
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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&
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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!3:5!2013.! ! In!this!presentation,!Dr.!Kelly!highlighted!some!of!the!work!being!done!by!the!Recovery!Research! Institute.!!He!then!went!on!to!outline!his!presentation.!The!outline!include:!! 1. A!brief!word!on!terminology! 2. Background!and!context! 3. Recovery!and!recovery!capital!and!the!importance!of!education!as!recovery!capital! 4. Theories!of!remission!and!recovery! 5. Mutual:help!organizations!research,!recovery!theory,!and!implications!for!CRCs! ! He!summarized!the!presentation!in!the!following!point:! The!way!we!talk!and!write!about!individuals!with!substance:related!problems!may!trigger! certain!cognitive!schemas!that!can!have!unwanted!consequences!as!with!the!eating!disorders! field,!use!of!substance!use!disorder!terminology!may!help!reduce!stigma!and!increase! treatment!access/engagement!! Recovery!capital!is!a!key!component!of!the!recovery!construct!and!education!is!associated!with! building!self:esteem!and!hope!for!a!better!future!that!may!have!physical!as!well!as! psychological!and!emotional!health!benefits!(i.e.,!holistic)!! CRCs!provide!young!adults!a!de:stigmatizing!and!self:actualizing!recovery!normative! environment!that!promotes!and!provides!adaptive!social!bonds,!coping!skills,!and!competing! rewards!as!they!attempt!to!achieve!major!milestones!!
!!!!!!!!!!!!!!!!!!!!!!!!!!P.!O.!Box!6448!!Reno,!NV!89513!!Phone:!760:815:3515!!staciemathewson@me.com! !
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12:step/community!mutual:help!participation,!on!which!many!CRCs!are!based,!can!enhance! short!and!long:term!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!mutual:help! and!continuing!care!engagement!over!time!after!FSR!
!!!!!!!!!!!!!!!!!!!!!!!!!!P.!O.!Box!6448!!Reno,!NV!89513!!Phone:!760:815:3515!!staciemathewson@me.com! !
BUILDING RECOVERY CAPITAL: ADDICTION, RECOVERY, AND RECOVERY SUPPORT SERVICES

AMONG YOUNG ADULTS
John F. Kelly, Ph.D.

Massachusetts General Hospital and Harvard Medical School Department of Psychiatry
OVERVIEW
A Brief word on terminology
Mutual-help organization research, recovery theory, and implications for CRCs
Background and context
Theories of Remission and Recovery
Recovery and Recovery Capital and the Importance of Education as Recovery Capital
A WORD ON TERMINOLOGY AND STIGMA Most Stigmatized Nationally Internationally Poor access
SUDs most stigmatized of all social/health problems
National surveys show stigma one of main reasons people with SUD do not seek specialty care (SAMHSA, 2009)
WHO examined 18 most stigmatized conditions (eg. criminal, HIV, homeless) across 14 different countries (Room et al 2001) Drug addiction- #1 - most stigmatized Alcohol addiction- 4th most stigmatized
Ambivalence driven by stigma why only 10% seek specialty care
How we talk and write about these conditions and individuals suffering them does matter
How we talk and write about these conditions and individuals suffering them does matter
The study sought to determine whether referring to an individual as a substance abuser vs. having a substance use disorder evokes different judgments about behavioral self10 regulation, social threat, and treatment vs. punishment
TWO COMMONLY USED TERMS
Referring to someone as
a substance abuser
having a substance use
disorder
Causal Attribution (is it their own fault?)

Substance-Related Term Self-Regulation (can they control it?) Social Distance/ Social Danger (are they dangerous?) Punishment/ Treatment
3 Subscales: 1. Perpetrator- Punishment 2. Social threat 3.Victim-treatment
Doctoral-level clinicians (n=516) randomized to receive one of two terms. Mr. Williams is a substance abuser and is attending a treatment program through 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, until one month ago, when he was found to have two positive urine toxicology screens which revealed drug use and a breathalyzer reading which revealed alcohol consumption. Within the past month there was a further urine toxicology screen revealing drug use. Mr. Williams has been a substance abuser for the past 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 treatment program through 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, until one month ago, when he was found to have two positive urine toxicology screens which revealed drug use and a breathalyzer reading which revealed alcohol consumption. Within the past month there was a further urine toxicology screen revealing drug use. Mr. Williams has had a substance use disorder for the past six years. He now awaits his appointment with the judge to determine his status.
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 treatment need? An empirical investigation with two commonly used terms (2010) Journal of Drug Issues
14
IMPLICATIONS
Even without being consciously aware of it, well trained doctoral level clinicians judged the same individual differently and more punitively depending on which term they were exposed to Use of the abuser term may activate a negative cognitive schema that perpetuates stigmatizing attitudes these could have broad stroke societal ramifications for treatment/funding Individuals with eating related problems are uniformly described as having an eating disorder NOT as food abusers Referring to individuals as suffering from substance use disorders is likely to diminish stigma and may enhance treatment and recovery
OVERVIEW
DRUG AND ALCOHOL IMPACT

Public health
#1 public health problem (Institute for Health Policy, 2001; CASA, 2011) Of all disease, disability, and deaths due to all psych conditions, AUD alone = 36% $500 billion in US each year (lost productivity, criminal justice, medical costs) Excessive alcohol consumption costs society $2 per drink (CDC, 2011) SUD leading cause of mortality - alcohol leading risk factor worldwide among males 15-59 Opiate overdose leading cause of accidental death nationwide
Onset of long-term problems occur during adolescence/young adulthood 90% adults with dependence start using before age 18 50% of adults start using before age 15
Financial
Mortality
Prevention
Comparison of the magnitude of the ten leading diseases and injuries and the ten leading risk factors based on the percentage of global deaths and the percentage of global 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 physical activity
ECONOMIC COSTS TO SOCIETY

$450
$400
$350
$300
$250 Economic cost (in billions)
$200
$150
$100
$50
$0 Alcohol and Illicit drugs Diabetes Obesity Smoking Heart disease
Bouchery et al. (2011), CDC (2012), US Department of Justice (2011)
% USING PRIOR TO AGE 15

35% 30%
25%
20% % using
Alcohol use Marijuana
Cocaine
15% Hallucinogens
10%
5%
0% 1934-1944 1945-1955 1956-1960 1961-1965 1966-1970 1971-1975 1976-1980 1981-1985 1986-1990
Adapted from: Johnson and Gerstein (1998) Am Jnl Public Health, 88, 1, 27-33
PREVENTION
% MEETING DSM-III-R LIFETIME ALCOHOL

DEPENDENCE CRITERIA
35%
30%
25%
20% Male (n=509) 15% Female (n=545)
10%
5%
0% 1910-1929 1930-1939 1940-1949 1950-1959 1960-1979
Birth Cohort 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.
SUBSTANCE USE DISORDERS (SUD) IN THE PAST YEAR AMONG PERSONS AGE 12 OR OLDER
PREVALENCE OF DSM-IV ALCOHOL DEPENDENCE ACROSS THE LIFESPAN (NESARC)
Source: Grant, Dawson et al, 2004
SUBSTANCE USE AND PROBLEM ONSET AND OFFSET

National Survey on Drug Use and Health (NSDUH) Age Groups
100 90
Severity Category
80
70 60 50
No Alcohol or Drug Use

Light Alcohol Use Only
Any Infrequent Drug Use

Regular AOD Use Abuse Dependence 14-15 16-17 18-20 21-29 30-34 35-49 50-64 65+
40
30 20
10 0
12-13
NSDUH and Dennis & Scott
SERIOUS PSYCHOLOGICAL DISTRESS (NSDUH, 2007)
GENERAL MOBILITY: 2011-2012 U.S. CENSUS

30 25
25
25
20 18 15 14 10 10 13 10 8 5 7 6 % Residential Change
0 15-17 18-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64
age
WHY DOES SUD ONSET IN YOUNG PEOPLE? 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 selfdetermination, but objective psychobiological reality = continues to be gradual developmental changes - impulse control, self-regulation, risk appraisal (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 with incongruency between subjective perceptions and objective reality creates new risks & challenges particularly regarding alcohol/drugs
REGIONAL VARIATION IN RATES OF PROBLEM USE

Figure 5.3 Alcohol Dependence or Abuse in Past Year among Persons Aged 18 to 25, by State: Percentages, Annual Averages Based on 2008 and 2009 NSDUHs
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH, 2008 and 2009
29
REGIONAL VARIATION IN RATES OF PROBLEM USE

Figure 2.3 Illicit Drug Use in Past Month among Persons Aged 18 to 25, by State: Percentages, Annual Averages Based on 2008 and 2009 NSDUHs
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH, 2008 and 2009.
30
COLLEGE YOUTH NATIONAL PREVALENCE OF SUBSTANCE USE

Full-time
students: 49% engage in hazardous use & 25% meet criteria for SUD (8.5% in general population) Consequences of substance misuse in students:
alcohol-related deaths/injuries, arrests, unplanned sex, sexual violence, fights, poorer health, academic problems
College campus considered a pro-drug culture
and substance use is viewed as a harmless rite of passage 37% of college students fear seeking help because of social stigma, and of those who meet the SUD criteria only 6% sought help (10% in general populations)
(Bell et al, 2009)
Developmental Milestones: SUD in emerging adults by College Enrollment
NSDUH: Heavy Alcohol Use among Adults Aged 18 to 22, by College Enrollment: 2002-2005
HELP-SEEKING BEHAVIOR BY CURRENT

COLLEGE ENROLLMENT STATUS
Research Question: What is the utilization and perceived need for alcohol treatment services among college-age young adults according to their educational status?
Sample: 11,337 young adults (18-22 yrs) who were either full-time college students, part-time college students, non-college students or nonstudents in the United States
Study Design: Cross-sectional data from the National Survey on Drug Use and Health (2002)
Wu L, Pilowsky DJ, Schlenger WE & Hasin D, (2007), Alcohol use disorders and the use of treatment services among college-age adults Psychiatr Serv, 58(2): 192-200.
LIKELIHOOD OF TREATMENT UTILIZATION

YOUNG ADULTS WHO MET CRITERIA FOR
PPY AUD
Odds of Treatment Utilization

Nonstudent
Compared to full time college enrolled AMONG young adults with PPY AUD, others substantially more likely to seek help for their AUD
Adjusted Odds Ratio

1.67
Analyses adjusted for demographic and clinical variables
Noncollege
2.87
Part-Time College
2.52
*<.05
Full-Time College
1.0 (ref) 1.0 1.5 2.0 2.5 3.0
Wu L, Pilowsky DJ, Schlenger WE & Hasin D, (2007), Alcohol use disorders and the use of treatment services among college-age adults Psychiatr Serv, 58(2): 192-200.
OVERVIEW
Recovery
capital (RC) is defined as the breadth and depth of internal and external resources that can be drawn upon to initiate and sustain recovery (Granfield & Cloud, 1999; Cloud & Granfield, 2004).
A Substance-related Problems (physical and mental health, housing, social relations, education and employment, meaning and purpose in life)
Addiction Severity
Addiction Remission
Recovery Capital (physical and mental health, housing, social relations, education and employment, meaning and purpose in life)
RECOVERY CONTEXTS: EDUCATION BASED RECOVERY

SUPPORTS
College education trumped money and social prestige as the pathway to health and happiness (Vaillant, 2011)
Despite big differences between core city sample and Harvard sample in parental social class, college-tested intelligence, current income and job status, health decline of inner-city men who obtained a college education was same as Harvard sample Education represents important recovery capital for young people
(Vaillant & Mukamal, 2001, Am. Jnl. Of
What are Recovery support services? Why are they so important?

Residential recovery homes (e.g., Oxford Houses) 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
Educational Recovery Capital (and CRCs) important given the typical Clinical Course for Substance Dependence and Recovery
Addiction Onset Help Seeking
Full Sustained Remission (1 year abstinent)
Relapse Risk drops below 15%
4-5 years
8 years
5 years
Selfinitiated cessation attempts
4-5 Treatment episodes/ mutualhelp
Continuing care/ mutualhelp
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).
Despite education important to long term health/well-being, college environment recovery unfriendly activities organized around alcohol/parties; recovery status secret Collegiate Recovery Communities (CRCs) provide safe place; sobrietyfriendly network Founding college programs: - Augsburg College - Texas Tech University - Rutgers (1st to offer oncampus residence hall for recovering students) Schools provide academic services and assistance with recovery and continuing care, but they are not treatment centers No experimental/comparative effectiveness trials to estimate extent and nature of benefits
TEXAS TECH UNIVERSITY: SINGLE GROUP PREPOST DESIGN
To enter the CRC, students need to have 1 year of recovery, attend at least 1 12-step on campus meeting per week, and succeed in their classes evaluation of the program: 2004-2005, N=82, (18-53 yrs old)
relapse rate within a semester was 4.4%; most maintained high GPA
Source: Cleveland et al. (2007)
AUGSBURG COLLEGE STEPUP PROGRAM

Support groups and sobriety-specific houses Outcomes
Annual avg relapse rate across 13 yrs = 13%, Down to about 7% in recent y
RUTGERS RECOVERY HOUSE DATA 2008-2011
Annual avg relapse rate across 13 yrs = 6%

Source: Laitman & McLaughlin (2011)
DATA FROM RECOVERY HIGH SCHOOLS
RECOVERY-RELATED OUTCOMES AMONG 72

RECOVERY HIGH SCHOOL GRADUATES
Surveys sent to Serenity High School alumni graduating 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 in college Collegiate recovery environment may normalize and destigmatize addiction/recovery increasing the chances of ongoing recovery or re-engagement with recovery
Lanham CC & Tirado JA, (2011). Lessons in sobriety: an exploratory study of graduate outcomes at a recovery high school. Journal of Groups in Addiction and Recovery, 6:245-263.
OVERVIEW
HOW DO CRCS AND RECOVERY SUPPORT SERVICES HELP? THEORIES OF REMISSION AND RECOVERY
Studies of treatment are often theory-based (e.g, Longabaugh and Morgenstern, 2002; Moos, 2007) However, studies of SUD remission and recovery are very seldom theory-based But, there are empirically supported theories that help explain the onset of substance use and SUD These same theories may be useful in helping explain SUD remission and recovery
The social contexts that underlie the initiation and maintenance of substance misuse may hold within them the potential for resolution of the problems they create (Moos, 2011)
Parallels in the onset and offset of SUD

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 of SUD

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 People want to stop using substances and recover for the same 4 main reasons: To feel good To feel better To do better Because others are doing it
Theory
Social Control Social Learning
Key process mechanisms for

Substance use Lack of strong bonds with family, friends, work, religion, other aspects traditional society Modeling and observation and imitation of substance use, social reinforcement for and expectations of positive consequences from use; positive norms for use 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, selfmedication Lack of alternative rewards provided by activities other than substance use Recovery Goal-direction, structure and monitoring, shaping behavior to adaptive social bonds Social network composed of individuals who espouse abstinence, reinforce negative expectations about effects of substances, provide models of effective sober living Effective coping enhances self-confidence and self-esteem
Stress and coping
Behavioral economics
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.
COLLEGIATE RECOVERY COMMUNITIES

Theory

Stress and coping
Source: Moos, RH (2011) Processes the promote recovery from addictive disorders.
ADDICTION RECOVERY MUTUAL AID ORGANIZATIONS

Theory

Stress and coping
SOCIAL SUPPORT IN COLLEGIATE RECOVERY

COMMUNITIES MAY BE ANALOGOUS TO THE MEDIATING EFFECTS SEEN IN 12-STEP RESEARCH
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
AA ATTENDANCE AND THE % CHANGE IN BOTH PRO-ABSTINENT AND PRO-DRINKING NETWORK TIES FROM TREATMENT INTAKE TO THE 9-M (OP SAMPLE)
Source: Kelly et al, 2011, Drug and Alcohol Dependence
AA ATTENDANCE AND THE % CHANGE IN BOTH PRO-ABSTINENT AND PRO-DRINKING NETWORK TIES FROM TREATMENT INTAKE TO THE 9-M (AC SAMPLE)
Source: Kelly et al, 2011, Drug and Alcohol Dependence
IS THE SOCIAL SUPPORT MODEL APPLICABLE TO COLLEGIATE RECOVERY COMMUNITIES?
Sample: 84 students participating in a collegiate recovery community (4 sites) Study Design: cross-sectional survey
Castiraghi AM (2012). Students perceptions of social support and recovery: The social support model used in replicating collegiate recovery communities. M.S. Thesis, Texas Tech University
CASIRAGHI THESIS SOCIAL SUPPORT

SUBGROUPS
Appraisal: emotional support consisting of caring, empathy, trust and love; having someone readily available to talk to about your problems Belonging: companionship; establishment of mutually valuable relationships through participation in social activities Tangible: instrumental support consisting of material items (e.g. food, clothing, furniture, financial help, or specific behavioral aid such as transportation) Validation: expression that optimistically influences a persons sense of self worth; confirmation of the appropriateness or normalcy of a persons behavior through social comparison
IS SOCIAL SUPPORT ASSOCIATED WITH RECOVERY QUALITY IN COLLEGIATE RECOVERY COMMUNITIES?
Sub-groups of social support (e.g. appraisal, belonging, tangible, validation) werent independently predictive of recovery quality Overall social support was directly associated with recovery quality
Younger students perceived greater amounts of recovery Conclusion: A holistic approach to social support involving all 4 elements of support may benefit recovering students
Castiraghi AM (2012). Students perceptions of social support and recovery: The social support model used in replicating collegiate reco very communities. M.S. Thesis, Texas Tech University
THEORY BASED COMPARISON BETWEEN COLLEGE AS USUAL VS. CRC FOR RECOVERING STUDENTS
College-as-usual Social control Maladaptive social bonds; hazardous/harmful substance use; antisocial behavior; let it all hang out Norm is party; alc/drug use modeled and reinforced; stigma associated with helpseeking CRC Adaptive social bonds; pro-social norms; monitoring/supervision; emphasis on education and achievement Norm is sobriety and recovery; abstinence reinforced; stigma/shame reduced with validation and praise for recovery status; help-seeking strongly encouraged Community predominant coping strategy; genuine confidence; approach coping; focus on positive experience and academic achievement Effective provision of alternative rewarding behaviors; success experience; validation
Social learning
Stress and Substance use is predominant coping coping strategy; substance induced confidence; avoidance coping Behavioral Substance use predominant economic reinforcer for commiseration or celebration
OVERVIEW
What are Recovery support services?

Residential recovery homes (e.g., Oxford Houses) 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
CRCs and building Social Recovery Capital

Most CRCs are based on 12-step principles and require 12-step attendance Does 12-step participation help young people? How much participation should be recommended?
How can CRCs benefit from the knowledge gained from 12-step research?
Young Adults and Mutual-help 0rganization Participation
Youth Barriers to 12-step Mutual help participation

Only about 14% under the age of 30 in AA and NA 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
Adolescent 12-step Participation across 8 Years into emerging adulthood

Participants (N=166; 40% female; M age 16; 75% Caucasian) consecutive admits to adolescent 12-step oriented, inpatient, SUD programs in San Diego (M stay = 4 wks)
Followed at 6m and 1, 2, 4, 6, and 8yrs (followup rates > 84%)
Neither demographic nor tx/clinical vars found associated with follow-up (ps>.27).
Source: Kelly, Brown, Abrantes et al, 2008; Alcoholism: Clinical Experimental Research
Results: Rates of Attendance

Any, Monthy, and Weekly AA/NA Attendance across 8 Years Following Inpatient Treatment 100% 90% 80%
% Attending AA/NA
70% 60% 50% 40% 30% 20% 10% 0% 0-6m 6m-1yr 1-2yr 2-4yr 4-6yr 6-8yr Follow-Up
Any Monthly Weekly
Source: Kelly, J.F., Brown, S. A., Abrantes, A., Kahler, C. H., & Myers, M. (2008) Social Recovery Model: An 8year 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 across 8 Years
100
% Attending AA/NA weekly 90 80 70 60
Infrequent User Abstainers
50
worse with time
40 30 20 10 0 6m 12m 24m 48m 72m 96m

Frequent User
Time
Lagged GEE Model of Youth Treatment Outcome in relation to AA/NA attendance over 8 Years
Parameter Estimate Standard Error 95% Confidence Limits 23.6656 -0.2614 -14.5526 -0.1772 -3.7722 -0.5761 -0.8727 1.0674 0.4304 50.9486 3.1462 -4.1234 0.0150 0.0090 1.4460 12.0065 2.8360 0.5757 Z P
Intercept Time Gender Pre-treatment PDA Moderate use Aftercare1 6m Formal Treatment2 AA/NA2 PDA2
37.3071 1.4424 -9.3380 -0.0811 -1.8816 0.4349 5.5669 1.9517 0.5030
6.9601 0.8693 2.6605 0.0490 0.9646 0.5158 3.2856 0.4512 0.0371
5.36 1.66 -3.51 -1.65 -1.95 0.84 1.69 4.33 13.56
<.0001 0.0971 0.0004 0.0980 0.0511 0.3991 0.0902 <.0001 <.0001
1= Sq root transformed; 2= Time varying covariate
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.
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. 75
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, prospective models)
Relation between Age Composition of Attended Meetings and Percent Days Abstinent for Adolescents
100 95 90 85 80 75 70 65 60 55 50
All adults Mostly adults Even mix Mostly teens All teens
Days Abstinent (3m) Days Abstinent (6m)
Kelly, Myers & Brown, (2005) Journal of Child and Adolescent Substance Abuse
Implications for CRCs?

12-step participation, particularly active involvement, appears to help young adults maintain recovery across time Homogeneity in terms of young adults may be helpful in terms of engaging young people with CRCs, but being too exclusive on age may limit the benefits that either greater life experience or longer recovery confers
Having a mix of age (life-experience) and different lengths of recovery may be optimally therapeutic
There are observed relationships between 3x/week attendance and complete abstinence early post treatment; recommended or required attendance frequency after achieving full sustained remission is unclear However, given that the risk of relapse after full sustained remission doesnt drop below 15% until 5 yrs, regular, weekly or twice weekly attendance or more ( especially in the first year re-enrolling in college) may provide continued recoveryspecific support and help buffer stress of adapting to high risk environment
CRCs: Cost-efficient Model of Recovery Support through facilitating 12-step involvement?
HEALTH CARE COST OFFSET CBT VS 12-STEP RESIDENTIAL TREATMENT

Compared to CBTtreated patients, 12step treated patients more likely to be in recovery, at a $8,000 lower cost per pt over 2 yrs ($15M total savings) $9,840 $7,400 $5,735 $2,440 Year 1 Year 2 Total
$20,000 $18,000 $16,000 $14,000 $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 $0 CBT $12,129
$17,864
TSF
The first study to examine how 12-Step participation affects medical 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)
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?
Cue Induced
Stress Induced
Social Psych
RELAPSE
Drug Induced
Bio-Neuro
MHO
89
Path diagram of the lagged mediational model for inpatient vs. outpatient and men vs. women.
(3-mo) AA Attendance
(15-mo) Alcohol Outcomes (PDA or DDD)
Baseline (BL) Covariates Age Race Marital status Employment status Prior alcohol treatment MATCH treatment group MATCH study site Alcohol outcomes (PDA/DDD) (BL) Self-efficacy Negative Affect (BL) Self-efficacy Positive Social (BL) Spiritual/Religious Practices (BL) Depression (BL) Social Network pro-abstinence (BL) Social Network pro-drinking (9-mo) Self-efficacy Negative Affect (9-mo) Self-efficacy Positive Social (9-mo) Spiritual/Religious Practices (9-mo) Depression (9-mo) Social Network pro-abstinence (9-mo) Social Network pro-drinking
90
DO MORE AND LESS SEVERELY ALCOHOL DEPENDENT INDIVIDUALS BENEFIT FROM AA IN THE SAME OR DIFFERENT WAYS?
Aftercare (PDA)
Self-efficacy (NA) 5% Depression 3%
SocNet: pro-drk. 24%
Spirit/Relig 23%
SocNet: proabst. 16%
effect of AA on alcohol use for AC was explained by social factors but also by S/R and through negative affect (DDD only)
Aftercare (DDD)
SocNet: pro-drk. 16% SocNet: pro-abst. 11%
Self-efficacy (NA) 20% Depression 11%
Self-efficacy (Soc) 34%
Spirit/Relig 21%
Outpatient (PDA)
Self-efficacy (NA) 1% Depression Spirit/Relig 2% 6%
Majority of Outpatient (DDD) effect of AA on Self-efficacy alcohol use for (NA) Depression 5% OP was 1% explained by social factors Spirit/Relig
SocNet: pro-drk. 29% 9%
SocNet: pro-drk. 33%
91
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
DO MEN AND WOMEN BENEFIT FROM AA IN THE SAME WAYS?

PERCENTAGE OF EFFECT OF AA ATTENDANCE ON OUTCOMES (PDA; DDD) FOR MEN AND WOMEN ACCOUNTED
FOR BY THE SIX MEDIATORS
92
MODERATED-MECHANISMS: AA EFFECTS MODERATED BY SEVERITY AND GENDER

CONCLUSIONS
Recovery benefits derived from AA differ in nature and magnitude between more severely alcohol involved/impaired and less severely alcohol involved/impaired; and between men and women
These differences reflect differing needs based on recovery challenges related to differing symptom profiles, degree of subjective suffering and perceived severity/threat, recovery challenges, and gender-based social roles & drinking contexts Similar to psychotherapy literature (Bohart & Tollman, 1999) rather than thinking about how AA or similar organizations work, better to think how individuals use or make these organizations work for them to meet their most urgent needs at any given phase of recovery
SO, COLLEGIATE RECOVERY PARTICIPANTS MAY USE DIFFERENT ASPECTS DIFFERENTLY

Theory

Stress and coping
HOW MIGHT THESE FINDINGS INFORM COLLEGIATE RECOVERY RELAPSE PREVENTION EFFORTS?
12-step basis and related TSF focus in CRCs may prove to be a cost-efficient method for maintaining recovery over time Perhaps the social relapse risks - although generally a more potent precursor among youth than adults - is relatively more important for males than females, whereas negative affect may be a more important factor for females More research is needed in this regard However, in general, sensitivity to mood regulation needs among women may reduce relapse risk and enhance quality of life; sensitivity to social risk needs among young men may boost social self-efficacy and reduce relapse risk
T S F
O T H
TSF Delivery Modes

Integrated into an existing therapy
Component of a treatment package (e.g., an additional group)
Stand alone Independent therapy
e.g., Project MATCH Research Group (1997); Litt et al, (2009)
e.g., Walitzer et al, (2008); Litt et al, (2009)
e.g., Kaskutas et al, (2009)
As Modular appendage linkage component
e.g., Timko et al, (2006; 2007; 2011); Kahler et al, (2005); Sisson and Mallams, (1981)
Research on alternative MHOs scarce
It is likely that many of the active ingredients in 12-step MHOs are also active in other MHOs and may mobilize the same kinds of intrinsic processes as do 12step
ARE SOCIAL NETWORKS A CAUSAL MECHANISM IN RECOVERY PATHWAYS?
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 RECOVERY PATHWAYS?
Predictor variables selected based on prior research or theory indicative of an association between each proposed predictor variable 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 score adjustment 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 not causal
100
Pro-drinkers and proabstainer network variables were found to exert enduring influence across a 3yr period over and above that of other influential social organizations like AA
101
OVERVIEW
SUMMARY
The way we talk and write about individuals with substance-related problems may trigger certain cognitive schemas that can have unwanted consequences as with the eating disorders field, use of substance use disorder terminology may help reduce stigma and increase treatment access/engagement Recovery capital is a key component of the recovery construct and education is associated with building self-esteem and hope for a better future that may have physical as well as psychological and emotional health benefits (i.e., holistic) CRCs provide young adults a de-stigmatizing and self-actualizing recovery normative environment that promotes and provides adaptive social bonds, coping skills, 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 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 mutual-help and continuing care engagement over time after FSR
103

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

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

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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.!

BUILDING RECOVERY CAPITAL: ADDICTION, RECOVERY, AND RECOVERY SUPPORT SERVICES

John F. Kelly, Ph.D.

Mutual-help organization research, recovery theory, and implications for CRCs

Background and context

Theories of Remission and Recovery

Ambivalence driven by stigma why only 10% seek specialty care

TWO COMMONLY USED TERMS

having a substance use

Causal Attribution (is it their own fault?)

3 Subscales: 1. Perpetrator- Punishment 2. Social threat 3.Victim-treatment

Mutual-help organization research, recovery theory, and implications for CRCs

Background and context

Theories of Remission and Recovery

DRUG AND ALCOHOL IMPACT

ECONOMIC COSTS TO SOCIETY

$250 Economic cost (in billions)

$0 Alcohol and Illicit drugs Diabetes Obesity Smoking Heart disease

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

% USING PRIOR TO AGE 15

Alcohol use Marijuana

0% 1934-1944 1945-1955 1956-1960 1961-1965 1966-1970 1971-1975 1976-1980 1981-1985 1986-1990

% MEETING DSM-III-R LIFETIME ALCOHOL

20% Male (n=509) 15% Female (n=545)

0% 1910-1929 1930-1939 1940-1949 1950-1959 1960-1979

PREVALENCE OF DSM-IV ALCOHOL DEPENDENCE ACROSS THE LIFESPAN (NESARC)

Source: Grant, Dawson et al, 2004

SUBSTANCE USE AND PROBLEM ONSET AND OFFSET

No Alcohol or Drug Use

Any Infrequent Drug Use

NSDUH and Dennis & Scott

SERIOUS PSYCHOLOGICAL DISTRESS (NSDUH, 2007)

GENERAL MOBILITY: 2011-2012 U.S. CENSUS

Desire forbidden (fermented) fruit associated with being grown up

REGIONAL VARIATION IN RATES OF PROBLEM USE

REGIONAL VARIATION IN RATES OF PROBLEM USE

COLLEGE YOUTH NATIONAL PREVALENCE OF SUBSTANCE USE

College campus considered a pro-drug culture

Developmental Milestones: SUD in emerging adults by College Enrollment

HELP-SEEKING BEHAVIOR BY CURRENT

LIKELIHOOD OF TREATMENT UTILIZATION

Odds of Treatment Utilization

Adjusted Odds Ratio

1.0 (ref) 1.0 1.5 2.0 2.5 3.0

Mutual-help organization research, recovery theory, and implications for CRCs

Background and context

Theories of Remission and Recovery

RECOVERY CONTEXTS: EDUCATION BASED RECOVERY

(Vaillant & Mukamal, 2001, Am. Jnl. Of

What are Recovery support services? Why are they so important?

Relapse Risk drops below 15%

Selfinitiated cessation attempts

4-5 Treatment episodes/ mutualhelp

Continuing care/ mutualhelp

TEXAS TECH UNIVERSITY: SINGLE GROUP PREPOST DESIGN

Source: Cleveland et al. (2007)

AUGSBURG COLLEGE STEPUP PROGRAM

RUTGERS RECOVERY HOUSE DATA 2008-2011

Annual avg relapse rate across 13 yrs = 6%

DATA FROM RECOVERY HIGH SCHOOLS

RECOVERY-RELATED OUTCOMES AMONG 72

Mutual-help organization research, recovery theory, and implications for CRCs

Background and context