Christine E. Grella, Ph.D. Department of Psychiatry and Biobehavioral Sciences UCLA Integrated Substance Abuse Programs (ISAP)

Semel Institute for Neuroscience and Human Behavior David Geffen School of Medicine at UCLA

Workshop on Integrating New Measures of Recovery from

Substance Use or Mental Disorder Into SAMHSA’S Data Collection Programs

February 24, 2016 The National Academies of Sciences, Engineering and Medicine

Defining and Operationalizing Recovery from Substance Use

Disorders

Topics

Background and overview How has recovery from substance use

disorders (SUD) been conceptualized and measured in research?

How do individuals define the meaning of “recovery”?

Historical Perspectives

Detail from the Taylor Map of New York (1879)

How has the concept of “Recovery” from SUD evolved? The concept of recovery from alcohol problems (i.e.,

intemperance) dates to the emergence of mutual self-help organizations within the context of 19th century temperance movements:

► Washingtonian Temperance Society (1840): non-sectarian, personal testimonials, temperance pledge

► Post Civil War evangelical temperance movements: gospel rescue missions, prayer meetings, focus on sinful nature

1935: Alcohol Anonymous (AA) founded – begins mass movement of mutual support groups for recovery

Recovery has broadened to have more general usage in society. White, W. L. (2005). Recovery: Its history and renaissance as an organizing construct. Alcoholism Treatment Quarterly, 23, 3-15.

Jellinek, E.M. (1946). Phases in the Drinking History of Alcoholics. Quarterly Journal of Studies on Alcohol.

Faces & Voices of SUD Recovery

http://www.facesandvoicesofrecovery.org/

International Quit & Recovery Registry: Web platform to crowd source research on SUD recovery

https://quitandrecovery.org/

Launched in September 2011, the International Quit & Recovery Registry seeks to understand what allows people to succeed in overcoming addiction. Led by Warren Bickel, PhD, director of the Addiction Recovery Research Center at Virginia Tech Carilion Research Institute, the registry taps the insights and experiences of people who are in recovery from an addiction.

Scientific interest in SUD recovery has increased

Google Scholar between 1959 and 2012 shows an exponential increase in the number of articles about substance use with “recovery” in the title in the past decade

Kaskutas, L.A., Witbrodt, J., & Grella, C.E. (2015). Recovery definitions: Do they change? Drug and Alcohol Dependence, 154, 85-92.

Growth in number of articles about recovery

How has recovery from SUD been conceptualized and measured in research?

Developmental/life course approach Age-related differences Maturational process

Clinical indicators of remission from SUD Symptom remission Covariates of recovery

Behavioral indicators of SUD recovery Focus on use/abstinence Multi-component indicators Cross-sectional status vs. person-centered trajectories

What is Recovery? Study

Developmental/Life Course Approach to Understanding Recovery from SUD

Developmental/life course approach

Dennis, M. & Scott, C.K. (2007). Managing addiction as a chronic condition. Addiction Science & Clinical Practice, 4(1), 45–55.

Source: U.S. National Household Survey on Drug Use and Health, 2001

Related constructs in developmental perspective

Natural recovery: Most people in the general population who have a SUD go into remission without any formal intervention.

Turning points: A life event, experience, or role transition that results in changes in the direction of a pathway or persistent trajectory over the long-term (e.g., marriage, childbirth, employment, incarceration, illness).

Recovery capital: Refers to assets or resources that individuals with substance use problems can use to cope with stressors and sustain recovery; e.g., having access to treatment services and supportive family, friends, and social networks, including 12-step groups.

Granfield, R., & Cloud, W. (2001). Social context and “natural recovery”: The role of social capital in the resolution of drug-associated problems. Substance Use and Misuse, 36, 1543-1570. Laudet, A., & White,W. (2008). Recovery capital as prospective predictor of sustained recovery, life satisfaction, and stress among former polysubstance users. Substance Use & Misuse, 43, 27−54. Teruya, C., & Hser, Y.I. (2010). Turning points in the life course: current findings and future directions in drug use research. Current Drug Abuse Review, 3(3), 189-195. Waldorf, D. (1983). Natural recovery from opiate addiction: Some social-psychological processes of untreated recovery. Journal of Drug Issues, 237-280.

“Maturing Out” of Narcotic Addiction

Study used records of narcotics addicts (N=45,391) reported to the Federal Bureau of Narcotics from federal, state, and local law enforcement and health agencies in the U.S. beginning in 1955.

Examined the extent to which individuals “were considered to be inactive” by the end of 1960.

16% were classified as inactive They ranged in age from 18 to 76 years. Average age of inactivity was 35.12 Average duration of addiction was 8.6 years; ranged

from 5 – 56 years

Winick, C. (1962). Maturing out of narcotic addiction. Bulletin on Narcotics, 14(1), 1-7

“Maturing Out” of Narcotic Addiction

Factors that influenced cessation: external circumstances relationships jeopardized by drug use weariness personality and insight incapacitating physical problems

Interpreted the findings to support that maturation out of addiction occur: as a reflection of their life cycle as a function of the length of their addiction

Winick, C. (1962). Maturing out of narcotic addiction. Bulletin on Narcotics, 14(1), 1-7

Maddux & Desmond: Re-examination of the “maturing out” hypothesis

Five conditions that “probably facilitated” recovery N %

Relocation away from usual source of drugs 19 36

Evangelical religious participation 13 25

Employment with drug abuse treatment agency 10 19

Probation or parole for 1 year or more 22 42

Alcohol substitution 23 43

Maddux, J.F., & Desmond, D. P. (1980). New light on the maturing out hypothesis in opioid dependence. UNODC - Bulletin on Narcotics, 1- 002.

Subjects were 248 opioid users in San Antonio who were treated at the PHS Hospital in Fort Worth from 1964-1967; their status was recorded through 1975.

Opioid drug use status of 248 subjects in July of each year, 1966-1975

Maddux, J.F., & Desmond, D. P. (1980). New light on the maturing out hypothesis in opioid dependence. UNODC - Bulletin on Narcotics, 1- 002.

George Vaillant’s longitudinal studies of male heroin addicts and alcoholics

Vaillant, G.E. (2003). A 60-year follow-up of alcoholic men. Addiction, 98(8), 1043–1051. Vaillant, G.E., & Milofsky, E.S. (1982). Natural History of Male Alcoholism IV. Paths to Recovery. Archives of General Psychiatry, 39(2):127-133. Vaillant, G.E. (1988). What Can Long-term Follow-up Teach us About Relapse and Prevention of Relapse in Addiction? British Journal of Addiction, 83(10), 1147–1157. Vaillant GE: (1966). A 12-year follow-up of New York addicts: IV. Some determinants and characteristics of abstinence. American Journal of Psychiatry, 123, 573-584.

Study sample: Alcoholics Study sample: Heroin users

268 Harvard undergraduates and 456 non-delinquent, socially disadvantaged Boston adolescents

100 men admitted to the US Public Health Service Hospital in Lexington, KY between 1952-1953

Participants were followed from age 20 to age 70–80 years

Participants were followed from age 20 to age 70–80 years

George Vaillant’s longitudinal studies of male heroin addicts and alcoholics

By age 70: 21% - 32% of surviving alcoholics were abstinent; 11% - 12% were still

abusing alcohol 35% of surviving heroin users had achieved stable abstinence (> 3 yrs)

and 25% were still using In both samples, “freedom from relapse” was associated with:

► community compulsory supervision ► a substitute dependence ► new relationships ► inspirational group membership (religion or AA)

Stable “pre-morbid” adjustment, especially employment, was most predictive of outcomes

Clinical Indicators of Recovery from SUD: Focus on Symptom Remission DSM-V Substance Use Disorder Early remission: lifetime SUD; at least 3 but less than 12 months with no symptoms (except craving) Sustained remission: lifetime SUD; at least 12 months with no symptoms (except craving)

Cumulative probability of remission from lifetime dependence by

type of substance in NESARC

Quintero, C.L. et al. (2010). Probability and predictors of remission from life-time nicotine, alcohol, cannabis or cocaine dependence: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Addiction, 106, 657–669.

Remission vs. Recovery in NESARC

Among those with lifetime AUD, past year-status: ► Still dependent: had >3 positive criteria for alcohol dependence ► Partial remission: did not meet the criteria for alcohol dependence, but

reported >1 symptoms of either alcohol abuse or dependence ► Asymptomatic risk drinker: past-year risk drinker, but no symptoms of

either abuse or dependence: Men: drank > 14 drinks/week, on average, or drank > 5 drinks in a single day > 1

time in past year. Women: drank > 7 drinks/week, on average, or drank > 4 drinks in a single day > 1

time in past year

► Low-risk drinker: non-risk drinker with no symptoms of either abuse or dependence

► Abstainer: did not consume any alcohol

Dawson et al. (2005). Recovery from DSM-IV alcohol dependence – United States, 2001–2001. Addiction, 100, 281 -292.

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Correlates of recovery from

alcohol dependence in NESARC Abstinent Recovery

Black, Asian, Hispanic (vs. White) Child <1 year old in household Attends religious services weekly Sought help that included 12-step

participation Marginal:

► Divorced or separated ► Employed with job problems ► Number of AUD symptoms

Non-Abstinent Recovery Never married (-) Unemployed or job problems (PY) Attends religious services weekly Smoking (-) Volume of alcohol consumed (-) Marginal:

► Divorced or separated ► Child <1 year old in household ► Past-year DUD (-) ► Has 1 medical problem (-); 2

problems (+)

Dawson et al. (2012). Correlates of recovery from alcohol dependence: A prospective study over a 3-year follow-up interval . Alcoholism: Clinical And Experimental Research, 36, 1268–1277.

Age-related correlates of drinking cessation (over 3-year follow-up)

among regular drinkers in NESARC

Dawson, D.A., Goldstein, R.B., & Grant, B.F. (2012). Prospective correlates of drinking cessation: Variation across the life-course. Addiction, 108, 712–722.

Younger (18 – 54) Older (55+) Non-age Specific • BL pregnant/has infant – • Nicotine or DUD - • Personality disorder (cluster A)- • Liver disease + • Incident retirement +

Family income > $70,000 – Volume of alcohol intake – Male + Asian ethnicity (vs. White) + Mood disorder + Onset of CVD +

College educated (vs. HS) – Black or Hispanic (vs. White) + Smoking cessation + Months since last drink +

Refining the Maturing Out Theory: Do rates of persistence change with age?

Decomposed DUD status at follow-up by age

Age effect is due to decreases in new onset and recurrence of DUD, whereas persistence is relatively stable across age

Role transitions co-varied with changes in status

Alvaro Vergés, A., et al. (2013). Refining the notion of maturing out: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. American Journal of Public Health, 103(12), e67–e73.

Behavioral Indicators of Recovery from SUD in Clinical & Cohort Studies: Focus on Abstinence and Psychosocial Functioning

Kaiser cohort study: Multi-component definition recovery from SUD

Chi, F.W., Parthasarathy, S., Mertens, J.R., et al. (2011). Continuing care and long-term substance use outcomes in managed care: Early evidence for a primary care-based model. Psychiatric Services, 62:1194–200.

Study Sample: Patients (N = 991) treated for SUD in a managed care system; Follow-up data were obtained from patients at 1, 5, 7 and 9 years following intake.

Remission was defined as abstinence in past 30 days or non-problematic substance use, which was defined as:

-drinking ≤4 times in the previous month

-not having ≥5 drinks on any given day

-not using marijuana more than once

-not using any drug other than alcohol or marijuana

-not having suicidal ideation, violent behavior or serious conflict with friends, family or colleagues

Latent measure of SUD recovery in Pathways Study (N=1,008)

Garner, B.R., Scott, C.K., Dennis, M.L., & Funk .RR. (2014). The relationship between recovery and health-related quality of life. Journal of Substance Abuse Treatment, 47(4), 293-298.

33-year Follow-up Study of Civil Addict Program (CAP) Sample

Original study sample: 581 men with a history of heroin dependence originally in the California Civil Addict Program in 1962-64, with 3 follow-up waves Characteristics: Ave age = 57 years at most recent follow-up wave; white (36.8%), Hispanic (56.2%), African-American (7.0%)

Followed for more than 30 years in 3 waves; deaths were documented with records from CDC-National Death Index

MV analyses used predictors from prior waves to model recovery at most recent wave; Stable recovery: at least 5 years of sustained abstinence from heroin (43%)

Hser, Y.-I., 2007. Predicting long-term stable recovery from heroin addiction: findings from a 33-year follow-up study. Journal of Addictive Diseases, 26, 51–60.

Natural History of Narcotics Addiction Among CAP Sample (N=581)

Hser, Y.I., Hoffman, V., Grella, C.E., and Anglin, M.D. (2001). A 33-year follow-up of narcotics addicts. Archives of General Psychiatry, 58, 503-508. Hser, Y.I., Evans, L., Grella, C., Ling, W., & Anglin, M.D. (2015). Long-term course of opioid addiction. Harvard Review of Psychiatry, 23(2), 76-89.

Comparisons between individuals with at least 5 years of abstinence vs. others

Recovery group (Mean = 19+9 years abstinence) and non-recovery group did not differ in substance use initiation, conduct problems, or family/school problems prior to age 15

Both groups had multiple treatment episodes (primarily methadone treatment) and self-help participation

In MV models, stable recovery at most recent follow-up was predicted by: Hispanic vs. non-Hispanic (-) Self-efficacy and coping skills (+) Psychological distress (-)

Hser, Y.-I., 2007. Predicting long-term stable recovery from heroin addiction: findings from a 33-year follow-up study. Journal of Addictive Diseases, 26, 51–60.

30-Year follow-up study of men and women sampled from methadone

treatment in California Original study sample: Participants were sampled from methadone maintenance clinics in 6 counties in Central & Southern California and interviewed in 1978-81

At follow-up in 2005-08: 47% verified as deceased; 71% of those still living were interviewed (N = 343); Average age: 58.3 for males, 55.0 for females

Trajectory group analyses generated 4 clusters of individuals with similar patterns of heroin use over time (person-centered analysis), controlling for time incarcerated; Bivariate comparisons across 4 trajectory groups, including patterns of other substance use

Grella, C.E., & Lovinger, K. (2011). 30-year trajectories of heroin and other drug use among men and women sampled from methadone treatment in California. Drug and Alcohol Dependence, 118, 251-258.

Trajectory group outcomes over 30-year follow-up study

30-Year Heroin Use Trajectories in a California Treatment-Based Cohort

Rapid Decrease(22%*): 60% women; less school problems, CD, ASP; most % time using alcohol & methModerate Decrease

(47%*): 46% womenGradual Decrease

(64%*): 39% women; more ASP, most % time incarceratedNo Decrease (84%*):

46% women; most % time MMT & using cocaine; youngest at 1st heroin use & arrest

N = 341; observed use based on joint heroin and AOD use trajectory models; odds of heroin use calculated per year beginning with year of heroin use initiation, excluding periods institutionalized; probability of group membership: all > 0.95; *percentage of time using heroin; Grella & Lovinger, 2011

Australian Treatment Outcome Study (ATOS): Past-month heroin abstinence over 11 years

Independent correlates of 5 or more years of heroin abstinence: female gender (OR =

1.73) not being currently

enrolled in a treatment program (OR = 2.16)

fewer discrete treatment episodes across the follow-up (OR = 0.90)

Darke et al. (2015). Patterns and correlates of sustained heroin abstinence: Findings From the 11-year follow-up of the Australian Treatment Outcome Study. Journal of Studies of Alcohol and Drugs, 76(6), 909-15.

How do Individuals Define The Meaning of “Recovery”: What is Recovery? Study

What Is Recovery (WIR) Study The “What is Recovery?” study aimed to empirically identify

the domains and specific elements of recovery as experienced by persons in recovery from diverse pathways.

An Internet-based survey was completed by 9,341 individuals who identified themselves variously as:

► In recovery (75%) ► Recovered (13%) ► In medication-assisted recovery (3%) ► Used to have a problem with alcohol and drugs (but no

longer do) (9%)

Kaskutas et al. (2014). Elements that define recovery: the experiential perspective. Journal of Studies on Alcohol and Drugs, 75, 999–1010.

What Is Recovery (WIR) Study Individuals rated 47 items as to how much each:

“belongs in a definition of recovery as you have experienced it.”

Factor analyses used to statistically reduce and group the elements into 4 factors (35 elements):

► Abstinence

► Spirituality

► Essentials of recovery

► Enhanced recovery

What Is Recovery? (WIR) Study

Sample Characteristics:

98% met DSM-IV criteria for dependence

59% endorsed alcohol as their primary substance; the remainder cited other drugs

Nearly all (96%) had attended treatment, 12-step and/or other recovery groups

54% were female, 82% over age 35, 80% had a some college/college degree, and most (88%) were white (88%)

A follow-up study with a sub-sample found relative stability in adherence to beliefs about recovery over approximately 3 years

WIR Study sample (N = 9,328)

Latent class analysis derived five groups based on their adherence to items in each of the four factors

• 12-step Traditionalists (52.7%) • 12-step Enthusiasts (21.6%) • Secular Class (10.5%) • Self-reliant Class (11.1%) • Atypical Class (4.1%)

Witbrodt, J., Kaskutas, L.A., & Grella, C.E. (2015). How do recovery definitions distinguish recovering individuals? Five typologies. Drug and Alcohol Dependence, 148, 109-117.

What Is Recovery? (WIR) Study The five groups differed in their beliefs and behaviors

on: abstinence, spirituality, 12-step participation, and social interactions.

12-step Traditionalists (57.7%): Strongly abstinence-oriented, with most indicating no alcohol use (87%), no use of non-prescribed drugs (72%), and no use of non-prescribed drugs (84%); high treatment and 12-step participation; strongly endorsed spirituality elements and identied as “in recovery.”

12-step Enthusiasts (21.6%): Mainly differed from the Traditionalists in less strongly endorsing: no use of non-prescribed drugs.

What Is Recovery? (WIR) Study Self-reliant Class (11.1%): Moderately endorsed abstinence

from alcohol and illicit drugs and no abuse of prescription drugs; lower endorsements to items pertaining to social interactions, e.g., learning how to get support, helping others, giving back, being able to have relationships.

Secular Class (10.5%): less endorsement of spirituality, more tolerant of non-abstinence, younger, fewer years in recovery, more often identified as used to have a problem, higher rates of using alcohol, and lower rates of 12-step participation.

Atypical Class (4.1%): Less endorsement of spirituality and abstinence; high intolerance for recovery being religious in nature; strongly endorsed being able to enjoy life as fundamental to recovery.

Implications for Measuring Recovery

Time frame: recovery is both a process of change and point-in-time status

Study design: longitudinal vs. cross-sectional

Sampling: general population probability surveys vs. clinical/targeted samples

Criteria: abstinence as critical component vs. multi-component measure

Abstinence/use: strict adherence vs. more tolerant definitions

Perspective of the individual: does self-definition matter?