Maintaining Resiliency and Sustaining Recovery: Ensuring That Recovery Lasts a Lifetime
May Maintaining Resiliency
Ask the Expert:
Alexandre B. Laudet, Ph.D., Director, Recovery Research Center, Institute for Research, Education, and Training in Addictions (IRETA)
1. Frustrating enough is working with the co-existing disorders in corrections. With criminal thinking in mind, what would your suggestions be for working with the felon with co-existing disorders and release pressures into their communities?
Persons with co-occurring mental health and substance use disorders have special recovery needs as do those involved in the criminal justice system and both present challenges. Thus while criminal justice involved persons who have co-occurring disorders present special challenges, they can attain and sustain recovery with the needed services and supports. Regardless of diagnosis or presence/absence of criminal justice involvement, one of the cardinal requirements of recovery is that the individual be able to establish a strong, sober support network in the community. This often requires making new social connections as substance users and especially criminally involved ones are likely to have spent much of their time with like-minded associates, sometimes for several decades. In this regard, family members and the extended community are particularly useful resources. Needless to say professional services are likely to be needed post-release from jail and they may include psychiatric/mental health counseling and/or medications as well as medications to assist recovery- e.g., methadone or buprenorphine for opiate dependent individuals. Thus in addition to the informal support of a sober network (that should include 12-step meetings or an alternative mutual aid group), your clients need to be connected with community-based professional services and this connection needs to occur while the individual is still incarcerated so that there is a pre-post jail ‘bridge’ in place when the individual is released. I would also direct you to a number of useful resources that are centralized at SAMHSA websites including resources for assisting persons with co-occurring disorders http://coce.samhsa.gov/ and SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP) http://www.nrepp.samhsa.gov/find.asp where you can search on key words including ‘criminal justice’ and ‘co-occurring disorders.’
2. What is your experience with recovery-oriented systems of care and recovery-community services organizations? Are we going in the right direction with these models, in your opinion? What, if anything, is missing from the ROSC, that needs to be added, changed, etc.?
Recovery-Oriented Systems of Care (ROSC, see http://www.pfr.samhsa.gov/rosc.html) is an emerging model of service delivery that represents two paradigmatic shifts in the substance use field relative to the prevalent care model: First, ROSC adopt a chronic or continuum of care model that is better suited to the chronic (relapse-prone) nature of substance use disorders especially in their most severe form, than the current model focused mostly on providing a short episode of intensive to a person in crisis. Second, rather than focusing most on symptoms (substance use), ROSC is person-centered and wellness focused, and builds on the strengths and resources of the individual, his/her family and community to promote overall improvements in functioning. Recognizing that substance use disorders affect multiple areas of life, ROSC is an integrated multi-system model of care centered on the whole individual rather than his/her symptoms. The systems element of ROSC is critical: In the absence of an integrated system of services that surrounds the individual, adapts to dynamic needs and provides continuity as recovery progress, there is a great likelihood that an individuals literally ‘falls through the cracks’ of a fragmented model of care where services are provided by different agencies in different locations, agencies that may not communicate or that have different policies, cultures, admission requirements and/or reimbursement structures. ROSC are designed to promote recovery, defined by SAMHSA as ‘is a process of change through which an individual achieves improved health, wellness, and quality of life.’ The ROSC model is increasingly being embraced by state and local agencies, most notably by the state of Connecticut and the city of Philadelphia that were among the first to transform their systems to ROSC. Many other states are in the process of transitioning, including my state of New York.
Recovery-community services organizations such as those funded by SAMHSA’s Recovery Community Services Program (RCSP) (see http://rcsp.samhsa.gov/ ) are generally peer led organizations that provide recovery support services to the community and work in coordination with treatment providers to complement and bridge professional services. Programming across these agencies varies and may include recovery coaching, support groups, life skills workshops, sober social events and outings.
Overall the answer to your question of whether we are going in the right direction is a resounding Yes. Both ROSC and recovery community services organizations are well suited to promote recovery in the broadest sense of the term: the former includes specialty care services while the later complements formal services. However, what remains critically needed in our field are (1) funding for research to build the science of recovery- a knowledge base on the many paths, patterns, service needs, resources used, and experiences of recovery among various groups (e.g., dually-diagnosed persons, women, veterans, youths, older people, minorities) that will inform policy, service development and funding, and allow us to monitor and evaluate recovery support services; and (2) workforce training that will be critical to the successful transition of our field from the current model of care to a recovery, continuum of care model.
3. What has been the most effective way or strategy to engage court-ordered clients in a group treatment program?
Court-mandated clients may be difficult to engage in the change process as their motivation may be largely external when they enter treatment. However research findings suggest that judicial mandates can in fact provide an opportunity for offenders with substance use disorders to access and benefit from needed treatment. For instance one large study compared the outcomes of court-involved mandated and non mandated patients and non-criminally involved patients one and 5 year after they entered treatment; the authors found that the groups made similar therapeutic gains in the long run and did not differ in treatment perceptions or satisfaction (e.g., Kelly, Finney & Moos, 2005). A number of evidence-based therapeutic strategies have been developed to engage substance users in treatment’ they can be located by going to the SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP) website http://www.nrepp.samhsa.gov/find.asp and searching by keywords such as ‘substance abuse treatment’ and ‘criminal justice.’ There are also some very good online guides of empirically based strategies to engage criminal justice populations in treatment such as NIDA’s ‘Principles of Drug Abuse Treatment for Criminal Justice Populations -A Research-Based Guide’ available for free download at http://nida.nih.gov/PODAT_CJ/index.html In addition to specific strategies of course, a supportive environment is always more conducive to therapeutic engagement and newly admitted clients may also be more opened to hearing from the experience of peers in terms of how the program was helpful and how to derive the maximum benefits from participation.
4. Why is the epidemic of pain killer addiction not being more fully addressed, on college campuses (where my daughter got her first prescription from her student health doctor), with ALL physicians (who are so very willing to prescribe and prescribe and prescribe), and with all drug companies? This is a devastating problem that could be eradicated from within. No person should have to go through what our daughter has gone through within a system that so completely enabled her.
This important and timely question. I am sorry that your daughter and your family had to go through this. I agree: in a perfect world no one should ever have to go through that. Fully addressing the issue as you state centers around supply reduction which is outside my area of knowledge I am afraid… Prescription abuse is increasing at an alarming rate and it is especially insidious. As you note, pain killers are easy for almost anyone to get (from doctors, relatives’ medicine cabinets, on the street and/or on the internet), they are highly addictive and many people who would never consider taking an illegal drug (e.g., heroin or crack) do not regard pain meds as ‘drugs’ because they are prescribed legally by a physician, someone we are taught to trust and turn to for help. Note of course that the medications themselves are usually safe when taken as prescribed and that is the crux of the matter: it’s not the medications themselves but rather the way they are used and abused that create problems. Ongoing efforts are made at several levels to limit access to prescriptions of abuse that range from educating physicians to regulating pharmacies and educating parents and youths but clearly more needs to be done. In the meantime, it’s important to raise awareness about the possible risks of pill abuse and to learn how to recognize and address signs of abuse and dependence, not only in youths but in everyone, especially vulnerable groups such as the elderly.
5. Suboxone is of help to those with opiate addiction. What pharmacological management is available for cocaine management?
Your question bears on Medication-Assisted Treatment (MAT), a form of pharmacotherapy, and refers to any treatment for a substance use disorder that includes a pharmacologic intervention as part of a comprehensive substance abuse treatment plan with an ultimate goal of patient recovery with full social function. In the United States, MAT has been demonstrated to be effective in the treatment of alcohol dependence with Food and Drug Administration approved drugs such as disulfiram, naltrexone and acamprosate; and opioid dependence with methadone, naltrexone and buprenorphine. A growing number of studies show the benefits of medication assisted recovery especially when complemented with psychosocial counseling. These benefits include decreases in substance use, infectious disease and criminal activities, increased treatment retention and employment rates, as well as improved survival. At this writing, however, Medication-Assisted Treatment is used primarily for dependence on opiates and on alcohol; pharmacotherapy for cocaine dependence is not currently available. Researchers are constantly working to identify and test innovative effective therapies for various manifestations of substance use disorders; I would encourage you to visit SAMHSA’s Medication-Assisted Treatment for Substance Use Disorders website http://www.dpt.samhsa.gov/ to learn more about ongoing efforts and therapies.
6. I have been sober for 18 months, and have done it mostly on my own- white knuckling my way through some hard emotions and situations while I fought the urge to drink. I know that AA and things like that are helpful to people, but I need something smaller and less group-oriented. I have no health insurance, and I am a single working parent. What can you recommend that I could do given my limited free time and finances, to find the kind of support I think I need to do more than just not drink? I want to have more of a life.
First, let me congratulate you for achieving and maintaining abstinence for 18 months under what must have been very challenging circumstances. Your experience is a testimony to the fact that when someone wants to stay abstinent above all else, it can be done. That being said I am sorry to hear that you had to do it on your own, white knuckling it as you put it (struggling through every single day with little help or relief): No one should have to go through this challenging task alone and there are indeed support resources available. While 12-step fellowships such as Alcoholics Anonymous (AA) are helpful to millions of people worldwide, you are certainly not alone in having determined that it is not for you. There are of course other addiction recovery supports available that are not based on the 12-step program such as Smart Recovery, most of which are listed at this URL http://www.facesandvoicesofrecovery.org/resources/support_home.php ; however, they may not appeal to you either as they too are based on a group format that you report is not comfortable to you. The lack of health insurance (though that may eventually change with health care reform) is certainly an added challenge. It sounds like you may fare better in a one-on-one situation such as counseling with a professional or with a recovery peer or recovery coach which can be one-on-one.
Many states now have state-specific recovery support resources listed on the website of their department of behavioral health or office of alcoholism and substance abuse services; you may need to do a bit of work to find the specific site for your state as agencies go by different names so the best strategy is to go to the homepage of your state (the website would be ‘your state name.gov’) and plug in ‘recovery’, addiction, substance use, or similar terms in the search field. Depending upon where you live, there are likely to be free or very low cost counseling services in community based agencies. Also depending on where you live, you may find useful Recovery Community Services Program agencies and/or Recovery Centers that are often peer led and offer a variety of recovery support services by visiting http://www.facesandvoicesofrecovery.org/resources/organizations.php A great resource to find many of these supports can be found on the website of SAMHSA’s Recovery Month (http://www.recoverymonth.gov/) which, despite of its name, is active all year round and may help you connect with recovery oriented organizations and/or individuals.
Another option worth exploring since you have internet access, is the growing number on web-based online recovery supports ‘chat rooms’ as well as the many groups that are now easily found on such social media websites as Facebook that has a thriving and ever expanding community of people in recovery worldwide – and you need not use your full or real name. There is even an iPhone app you can purchase for a small fee that is designed to provide recovery supports though I have not personally evaluated it. Overall, please know that recovery support resources come in many different forms and are found in many different ways. You may just have to work a bit harder than some others in view of your preference for non group support and lack of health insurance but you sure have demonstrated that your dedication to recovery which is the most important element! In closing I want to encourage you to explore some of the resources listed here and above all, to keep your recovery as your main priority no matter what. Best wishes.