Accepting the mantra that "Treatment Works," families, varied treatment referral sources and the treatment industry itself believe that responsibility for any resumption of alcohol and other drug use following service completion rests on the shoulders of the individual and not with the treatment program. This is unique in the annals of medicine. With other medical disorders, continuation or worsening of symptoms is viewed as an indication that the initial treatment is not effective for this particular patient and that changes in the treatment protocol are needed. In contrast, when symptoms continue or worsen following addiction treatment, it is the patient who is blamed and often punished. The stance is, "You had your change and you blew it! You must now suffer the consequences of your actions." And those consequences are often quite dire, including divorce, loss of children, loss of housing or educational opportunities, termination of employment, discharge from the military under less than honorable conditions, loss of professional licenses, loss of driving privileges, and incarceration, to name just a few. Such punishments are often meted out with an air of righteous indignation in the belief that the person for whom we have done so much has failed this chance we have given them. The question I am raising in this blog is: Was it really a chance?
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The threats to health that occur during active addiction have been widely communicated in the popular media and in the scientific literature, but the health profile of people in long-term recovery from substance use disorders remains something of a mystery. While one might assume that physical and emotional health rapidly improves following recovery initiation and stabilization, a health survey of Philadelphia and surrounding counties just published in the Journal of Psychoactive Drugs reveals a more complex and ominous picture.
In 2010, the Philadelphia Department of Behavioral Health and Intellectual disAbility Services contracted with the Public Health Management Corporation (PHMC) to incorporate recovery-focused items into PHMC's 2010 Southeastern Pennsylvania (SEPA) Household Health Survey of Philadelphia and four surrounding counties. The survey results reveal a recovery prevalence rate in the adult population of 9.45%--recovery defined in the survey as once having but no longer having an alcohol or drug (AOD) problem. That recovery prevalence rate is comparable to U.S. national surveys that have measured the rate of remission from substance use disorders, e.g., the percentage of adults who meet lifetime criteria for a substance use disorder but did not meet such criteria in the past year. The Philadelphia and national studies confirm the presence of a large population of people (more than 20 million in the U.S.) who have resolved a significant AOD problem. This large population of people quietly and invisibly living out their lives in long-term recovery defies the pessimism about recovery fueled by the media obsession with celebrities recycling through rehab or dying from drug overdoses.
The Philadelphia survey goes beyond affirming the significant prevalence of recovery in the general population to provide a detailed profile of the health of people in recovery. The results are sobering. People in recovery, compared to citizens not in recovery, are twice as likely to describe their health as poor and report higher rates of asthma, diabetes, high blood pressure, obesity and past-year emergency room visits. They are also more likely to report lifetime smoking (82% vs. 44%), current smoking (50% vs. 17%), exposure to smoke in their residence, no daily exercise and eating fast food three or more times per week. In terms of resources to address health concerns, people in recovery compared to the general population reported greater family/social isolation, lower income, less insurance coverage, and less likelihood of past year health screenings, primary health care and dental care.
A detailed review of these findings reveals the many burdens all too often brought into the recovery process--burdens that if unattended can plague personal health and quality of personal and family life for years to come. The findings also reveal the roles past and present nicotine addiction plays in these health problems. And they reveal the limited natural resources available to many people in recovery to address these problems. So what do these findings reveal about the state of professional care for AOD problem in the United States?
At a systems level, they expose a model of care that functions as an emergency room to provide acute biopsychosocial stabilization but is not designed to provide long-term health management for people in recovery. The management of other chronic health disorders (e.g., diabetes, hypertension, etc.) is viewed as requiring the management of global health (e.g., management of co-occurring medical conditions, diet, exercise, psychosocial stressors) over a prolonged if not lifelong period of time. It is time--no, past time--the treatment of the most severe and complex AOD problems was reconceived in this same way. Such approaches would move beyond brief episodes of symptom amelioration (recovery initiation and diagnostic remission) to the promotion of global health and quality of personal, family and community life in long-term recovery.
At its most practical level, the survey findings suggest that every person entering recovery should have an ongoing relationship with a primary care physician who is knowledgeable about addiction recovery and who can serve as an ongoing consultant on the achievement of health and wellness. It also suggests the need for addiction professionals and recovery support specialists to serve as a source of collateral encouragement and guidance in this process. It is time we broadened our vision beyond what we can subtract from people's lives in the short run to encompass what can be added to enrich those lives in the long term. And it is time we defined recovery to encompass smoking cessation. People in self-proclaimed addiction recovery continue to die in great numbers from nicotine addiction. They are dying of the conceptual blindness that sees no contradiction between present nicotine addiction and claimed recovery status. Through our silence, addiction professionals and peers in recovery participate in those deaths--collective acts for which we will be judged harshly in historical retrospect. (Can you hear the future voices: "Celebrating addiction recovery in smoke-filled rooms? What the hell were they thinking back then?!")
At a personal level, the Philadelphia survey is a call for each person in recovery to take ownership of his or her health. Such ownership includes a physical inventory of the legacies of addiction and making amends for the injuries and neglect inflicted on one's own body. Those inventory and amends processes often produce a deep and enduring commitment: "With stable feet and cleared vision, I will begin and sustain the process of healing myself--and I will reach out to help heal others."
For most people new to recovery, the first 18 months following addiction treatment are critical to building lasting sobriety. With an emphasis on recovery coaching, monitoring, verification reports and even drug testing, Hazelden’s new post-treatment program, Hazelden Connection, offers additional recovery support and services during that decisive 18-month period.
Addiction is a chronic disease with relapse rates similar to rates for diabetes, hypertension and asthma, explains Janelle Wesloh, executive director of recovery management for Hazelden. "What this means for Hazelden patients is that getting sober is their first step. Learning how to stay sober is a lifelong journey. We start patients off with the web-based MORE® program to begin their transition from treatment, but many people need more intensive support and attention. And, with the right level of care and support, we know that the likelihood of long-term sobriety increases greatly."
Hazelden alumni already have access to a variety of continuing care resources and services through the online MORE program, continuing care groups, recovery-sensitive mental health services, sober residences and outpatient programs. The new program leverages and consolidates these important resources and more under the direction of a Hazelden Connection coach.
"Hazelden Connection does for the average person what intensive monitoring and diversion programs of boards and licensing agencies do for health care professionals, pilots and lawyers," explains Wesloh. "And people who are under the guidance of a licensing board post-treatment have excellent outcomes.
Providing first-rate addiction treatment is a given at Hazelden, says Richard Choate, manager of recovery support and the former supervisor of the Simpson Unit on Hazelden’s Center City campus. "Now we are looking beyond the treatment experience and providing guidance and support as people transition out of care. We want to be there for them as they’re moving out from Hazelden’s cocoon of care and support. If they stumble, we can help them get back on track. We can intervene quickly. That’s critical."
Hazelden Connection extends the continuum of care beyond treatment, using protocols and techniques developed from time-tested recovery management methodologies.
Coaches are keyThe main role of the Hazelden Connection coach is to be an advocate for recovery. This starts with an initial meeting during treatment to align the newly recovering person, the family, the treatment counselor and the Hazelden Connection coach. This team provides the foundation of support and accountability during the critical early months of recovery. An individualized continuing care plan, developed by Hazelden’s interdisciplinary treatment team, informs and guides the work of the Hazelden Connection recovery coach.
In addition to ongoing communication with the person in recovery, the Hazelden Connection coach meets with other parties, including family, employers or school administrators, as appropriate. Telephone-based communication begins the first week post-discharge and gradually decreases in frequency over the 18-month program. Contact sessions include ongoing screening of individual needs and intervention for emerging issues, with solution-focused coaching to address the person’s current level of action toward recovery goals. The family receives coaching in tandem, gaining the education, access to resources and guidance they need to understand and support their loved one’s recovery. In addition to monitoring the newly recovering individual, the coach compiles monthly verification reports that are sent to key stakeholders including the participant, family, and other contacts such as the legal system or employer.
This intensive level of post-treatment support and assistance is ideal for people who need additional encouragement and accountability, such as those facing legal issues, custody matters, or loss of their professional license; people who’ve been in treatment multiple times; and students who are returning to college.
"We are excited to extend Hazelden’s reach of hope and help in this whole new way," adds Wesloh.
Published in the Voice, Spring 2011
There seems to be a growing a trend that addiction is all about the cravings, and if you focus on reducing an addict’s cravings then the addiction will be essentially cured. This is a natural assumption, but understanding addiction will clarify this misnomer. The reason an addict is addicted to chemicals (alcohol, etc.) and seemingly can’t live without them is that they usually felt bad prior to having substances in their body. They have never felt as good as the average, non-addicted person.
As mentioned, they have what Blum identified as the Reward Deficiency Syndrome. This syndrome causes their mind to develop an operating system that is more self-centered than the average person, because they simply can’t experience satisfaction, appreciation and gratitude. Mood altering substances temporarily and artificially correct this abnormality. 12-step and faith-based programs also correct the Reward Deficiency Syndrome. Unfortunately, addicts will despise the notion of any constructive group involvement on an on-going basis. In contrast, they are comfortable in social setting that support the use of substances as a way of life.
Many times addicts have one or more other disorders in addition to their addiction. These are called co-morbidities and frequently include: depression, anxiety, ADHD, insomnia, obsessionality, and panic attacks. These comorbid issues create obstacles to an addict’s recovery. For example, it is challenging to be present in treatment or recovery groups while suffering with these issues.
Understanding addiction means acknowledging the reason for an addict’s intense resistance to effective addiction treatment, especially if it is on-going such as participating in a 12-step or faith-based program. Intervention always triggers an intense fight or flight response. Since an addict views substances with the same importance as air, water and food, an effective treatment will evoke a intense survival reaction.
Aftercare Definition - From National Library of Medicine & SAMSHA
Aftercare, or continuing care, is the stage following discharge, when the client no longer requires services at the intensity required during primary treatment. A client is able to function using a self-directed plan, which includes minimal interaction with a counselor. Counselor interaction takes on a monitoring function. Clients continue to reorient their behavior to the ongoing reality of a pro-social, sober lifestyle. Aftercare can occur in a variety of settings, such as periodic outpatient aftercare, relapse/recovery groups, 12-Step and self-help groups, and halfway houses. Whether individuals completed primary treatment in a residential or outpatient program, they have at least some of the skills to maintain sobriety and begin work on remediating various areas of their lives. Work is intrapersonal and interpersonal as well as environmental. Areas that relate to environmental issues, such as vocational rehabilitation, finding employment, and securing safe housing, fall within the purview of case management.
Because case managers interact with the client in the community, they are in a unique position to see the results of work being done in aftercare groups and provide perspective about the client's functioning in the community. Recent findings suggest that the case management relationship may be as valuable to the client during this phase of recovery as that with the addictions counselor (Siegal et al., 1997; Godley et al., 1994). Aftercare is important in completing treatment both from a funding standpoint (many funders refuse to pay for aftercare services), as well as from the client's perspective.
Timothy Harrington is passionate about sharing information with people on ways to strengthen the link between treatment and long-term recovery.