Building the Science of Recovery

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1 Buildig the Sciece of Recovery RESEARCH BRIEF JANUARY 2009 Compiled by: Alexadre Laudet, PhD, Natioal Developmet ad Research Istitutes, Ic. Edited by : Michael T. Flaherty, PhD, Istitute for Research, Educatio ad Traiig i Addictios ad Debra Lager, MSc, MPA, Istitute for Research, Educatio ad Traiig i Addictios Istitute for Research, Educatio ad Traiig i Addictios

2 2009 IRETA NeATTC/IRETA Regioal Eterprise Tower 425 Sixth Aveue, Suite 1710 Pittsburgh, PA (412) Compiled by Alexadre Laudet, PhD, (of Natioal Developmet ad Research Istitutes, Ic.) ad edited by Michael T. Flaherty, PhD ad Debra Lager MSc, MPA, (both of the Istitute for Research, Educatio ad Traiig i Addictios) ad published by the Northeast Addictio Techology Trasfer Ceter (NeATTC), Regioal Eterprise Tower, 425 Sixth Aveue, Suite 1710, Pittsburgh, PA This publicatio was prepared by the Northeast Addictio Techology Trasfer Ceter uder a cooperative agreemet from the Substace Abuse ad Metal Health Services Admiistratio s (SAMHSA) Ceter for Substace Abuse Treatmet (CSAT). All material appearig i this publicatio except ay take directly from copyrighted sources is i the public domai ad may be reproduced or copied without permissio from SAMHSA/CSAT or the author. Citatio of the source is appreciated. This material should ot be reproduced ad distributed for a fee without writte authorizatio from the Northeast ATTC. Citatio of the source is appreciated. For more iformatio o obtaiig copies of this publicatio, call (412) At the time of publicatio, Eric Broderick, DDS, MPH served as the Actig SAMHSA Admiistrator. H. Westley Clark, MD, JD, MPH, CAS, FASAM served as CSAT Director, ad Catherie D. Nuget served as the CSAT Project Officer. The opiios expressed herei are the views of the author ad do ot reflect the official positio of the Departmet of Health ad Huma Services (DHHS), SAMHSA, or CSAT. No official support or edorsemet of the opiios expressed i this documet by DHHS, SAMHSA, or CSAT is iteded or should be iferred. Produced uder a grat ad cotract fuded by the Ceter for Substace Abuse Treatmet, Substace Abuse ad Metal Health Services Admiistratio, U.S. Departmet of Health ad Huma Services; Ceter for Substace Abuse Treatmet, 5600 Fishers Lae Rockwall II, Suite 618, Rockville, Marylad 20857, Its cotets are solely the resposibility of the authors ad do ot ecessarily represet the official views of these agecies. Grat No. 2 UD1 TI


4 PURPOSE, VISION... AND AN INVITATION The sciece of addictio has made great strides, largely thaks to the geerous fudig of federal agecies such as the NIH ad SAMHSA, ad the visio of their leaders. The empirical kowledge that has resulted from this fudig is ivaluable to the prevetio ad treatmet of addictio ad to iformig policy ad fudig decisios that affect ot oly the lives of addictio-affected persos but also that of their families, commuities ad of society at large. Researchers have made may strides i the sciece of addictio, some of the most sigificat of which have led to cosistet improvemet i the methods used to ivestigate its etiology ad treatmet. Lookig to other biomedical fields to ehace research ad treatmet strategies withi addictios, we have embraced methodological gold stadards such as large-scale radomized cliical trials as well as effective or promisig pharmacotherapies that, as a adjuct to traditioal treatmet, have the potetial to improve the lives of millios. These iclude methadoe, bupreorphie, acamprosate, altrexoe, suboxoe, ad umerous others. I usig the most sophisticated scietific methods to urgetly pursue the cure to a social ill whose cosequeces exted well beyod the addicted idividual (leadig to issues such as HIV/AIDS, Hepatitis C, domestic violece, family disitegratio, social istability, ad devastated commuities), we must ot lose sight of the pheoemeology of addictio ad its solutio recovery to the idividual. Oe of the most sigificat discoveries withi the field is idetificatio of addictio as a chroic (some say relapse-proe ) coditio. The cardial trait of chroicity is that there is o cure; however, symptoms ca be maaged ad the coditio arrested or remitted. Ulike other biomedical fields ad illesses, we curretly lack criteria to recogize or quatify remissio from addictio or how that remissio is best sustaied. This however, is the cocer of the addictio professioal. Millios of formerly addicted idividuals worldwide are livig proof that remissio recovery from addictio is a reality ad as may have said to us whe preparig this Brief, they do ot eed a defiitio or a set of criteria. But scietists do, as they must. Therefore, the task of researchers must be to catch up to this large yet uquatified ad uder-ivestigated group of idividuals to lear from their experieces i order to iform services ad policy i a icreasigly recovery-orieted system of care. As stated later i this Brief, the sciece of addictio ad the sciece of recovery are complemetary, ot mutually exclusive. If it is a illess, we must elucidate welless with the same reletless commitmet to the highest scietific stadards that guide the sciece of other ills. We must also recogize that whe seekig to elucidate remissio or the experiece of recovery from a bio-psycho-social coditio that impairs early all areas of fuctioig ad has for may a spiritual compoet, traditioal scietific strategies may fail us at times. The questios we ask may differ from those we address whe explaiig pathology. The methods we use eed to iclude the lived experiece of our subjects. Our ultimate task is to develop a sciece that adheres to the strictest stadards of excellece while describig welless i its may forms to iform services ad ultimately improve lives. This brief was udertake as a prelimiary roadmap to this scietific destiatio. It is desiged to both highlight what is curretly kow about addictio ad recovery ad to emphasize the eed for research that focuses o recovery a very real yet largely uexamied pheomeo kow curretly mostly through persoal accouts ad a emergig sciece that caot progress if held strictly to the questios ad methods defied i the sciece of addictio pathology. This Brief delieates the key questios eeded to icrease our uderstadig of recovery as idetified by practitioers, researchers, policymakers ad the recovery commuity. It is our hope that this work will ow serve as a ope ivitatio for all to participate i further defiig addictio ad recovery. By doig so, we ca all cotribute to expadig our kowledge base iformig these topics as well as defiig more clearly our uderstadig of the illess, how it is experieced, ad how it ca be overcome. The ultimate visio of this work is to provide practitioers with the kowledge ecessary to offer addictio-affected idividuals better opportuities to achieve ad sustai log-term recovery. 2

5 BACKGROUND I a semial report o the practice of medicie, especially as it relates to the maagemet of chroic illesses, the Istitute of Medicie (IOM; 2001:1) stated that the America health care delivery system is i eed of fudametal chage. Too ofte, patiets do ot receive care that meets their eeds ad is based o the best scietific kowledge (IOM, 2001: 145). Cosistet with these statemets, i a survey of health care systems i five idustrialized atios, adults i the US were least satisfied with their health care system (Commowealth Fud, 2002). The IOM report sparked umerous efforts to examie the healthcare delivery system both from the physical ad behavioral health perspectives. I 2004, seekig to address the issues idetified by the IOM report, the Istitute for Research, Educatio ad Traiig i Addictios (IRETA) coveed a group of leaders i addictios to study the delivery of substace abuse treatmet services ad to develop a commo visio for the prevetio, itervetio, treatmet, ad recovery from substace use disorders. The guidig cocept of this effort was the coceptualizatio of addictio, i its most severe form, as a chroic disorder. The proceedigs of this multi-year effort ad the resultig model from the collaborative group process, the Resiliecy, Welless, ad Recovery Model, was published i 2006 (Flaherty, 2006). The model emphasized the eed to adopt a chroic disease cotiuity of care model to address substace use disorders, ad to iclude early itervetio ad recovery supports as a itegral part of care. Subsequetly, IRETA worked with William White ad Dr. Erest Kurtz, to publish a guide for addictio couselors detailig a key aspect of the ew model of addictio services, the itegratio of recovery support services with treatmet (White & Kurtz, 2006). The guide preseted a large body of empirical evidece idicatig that active likage ad use of recovery support services durig ad after treatmet could sigificatly ehace treatmet ad recovery outcomes (Deis, Scott, & Fuk, 2003; Fioretie & Hillhouse, 2000; McKay, 2005; Moos & Moos, 2005; Scott, Foss, & Deis, 2005). The itegratio of recovery support services with treatmet as described is just oe aspect of a larger system desiged to focus o ad better support recovery a recovery-orieted system of care (ROSC) ( ROSC is a etwork of formal ad iformal services developed ad mobilized to sustai log-term recovery for idividuals ad families impacted by severe substace use disorders. The system i ROSC is ot a local, state, or federal treatmet agecy but a macro-level orgaizatio of a commuity, a state, or a atio (White & Kurtz, 2006: 13). Implemetig such a system etails a fudametal paradigmatic shift from the prevalet acute care model where services are delivered i discrete, itese episodes focusig o symptom elimiatio for a specific problem ad directed by professioals, to a cotiuity of care paradigm where welless is the goal ad log-term recovery is viewed as self-sustaiable (White & Kurtz, 2006: 9-10). As empirical evidece cotiues to build, supportig adoptio of this ew model, it is begiig to be put ito practice. As evideced by these early implemetatios ad curret recovery-related research, the model presets may challeges to service developers, policy makers ad researchers, ad has geerated may questios. These questios eed to be addressed to guide the field toward the implemetatio of this ew addictio service visio ad addressig them fully has required the ivolvemet ad collaboratio of all stakeholder groups, icludig the recovery commuity as well as more traditioal professioal parters. IRETA took the leadership i movig this ageda forward by coordiatig two key iitiatives i The first was to orgaize a Recovery Symposium, held o May 1-2, 2008, that built upo the may atioal ad regioal recovery-orieted iitiatives ad that brought together represetatives of all key stakeholder groups. The evet featured a half-day workig meetig i which a group of diverse leaders represetig substace use treatmet service providers, researchers, recovery, policy, ad fudig agecy represetatives came together to lear from each other s experieces related to desig ad implemetatio of recovery-orieted systems of care icludig exploratio of barriers ad lessos leared. The secod day of the symposium etailed a full day of presetatios addressig umerous aspects of the recovery movemet ad represetig the perspective of the recovery commuity, federal, state ad city agecies, policy makers, service providers ad researcher icludig Dr. H. Westley Clark (Substace Abuse ad Metal Health Services Admiistratio/ Ceter for Substace Abuse Treatmet), Dr. George DeLeo (Natioal Developmet ad Research Istitutes, Ic.), Kare M. Carpeter-Palumbo (New York State Office of Alcoholism ad Substace Abuse Services), ad may others. (see Appedix 1; Videos of the Symposium are available at This diversity of views is key i creatig, fudig, deliverig ad evaluatig a recovery orieted service model that ca best address the eeds of idividuals ad commuities affected by substace use disorders. The day-log symposium icluded the presetatio ad discussio of a ageda for the Sciece of Recovery as detailed below, that was followed by commetaries from atioal leaders icludig, Dr. Robert Forma (Alkermes, Ic.), Dr. Mark Willebrig (Natioal 3

6 Istitute of Alcohol Abuse a Alcoholism), Dr. Timothy Codo (Natioal Istitute o Drug Abuse), ad Drs. A. Thomas McLella ad Dei Carise (Treatmet Research Istitute). IRETA s secod iitiative to itegrate the recovery visio ito the addictio field etailed parterig with other orgaizatios (Great Lakes Addictio Techology Trasfer Ceter ad Philadelphia Departmet of Behavioral Health ad Metal Retardatio Services) to support the preparatio of a moograph authored by William White layig out the empirical support for the move to ROSC (White, 2008; The moograph was joitly published i Jue of 2008 ad is the first ad most comprehesive systematic review of the literature to support trasitio to ROSC ad the cocrete strategies that will make the visio of ROSC a reality. This brief grew out of both, plaig for the recovery symposium ad the clear eed, highlighted i William White s 2008 moograph, for trasformatio of substace abuse service delivery so that it better promotes log-term recovery. Doig so will require a robust ad thorough empirical basis the sciece of recovery. 4

7 INTRODUCTION I preparatio for the recovery symposium described above, the symposium plaig group solicited iput from various stakeholder groups about the types of questios we eed to be able to aswer to promote log-term recovery, iform recovery orieted systems of care (ROSC) ad recovery maagemet (RM) ad to miimize curret barriers to recoveryorieted services. We obtaied extesive iput from the recovery commuity orgaizatios (based o the atioal work of Faces ad Voices of Recovery i which the orgaizatio gathered questios ad issues of cocer to persos i recovery); surveyed service providers atiowide represetig all treatmet modalities ad therapeutic orietatios, fudig source (public ad private), agecy size, ad geography (urba ad rural); ad obtaied iput from the research commuity. The resultig feedback was the orgaized ito broad categories that are preseted i this brief ( What do we eed to kow? ). A more detailed list of topics ad questios is preseted i Appedix 2. A prelimiary summary of this brief was preseted at a closed pre-symposium meetig of key stakeholders o May 1; audiece feedback from this presetatio was icorporated i this fial versio of the brief. This brief summarizes the eed for ad promise of the Sciece of Recovery, presets key research questios, ad closes with a summary of curret obstacles to coductig recovery-orieted research ad suggestios for possible future directios. WHY DO WE NEED A SCIENCE OF RECOVERY? Decades of federally-fuded research have resulted i a vast kowledge base about the ature (etiology, causes ), patters, cosequeces ad treatmet of addictio. Iformatio o the prevalece of alcohol ad drug use i the past moth/year is easily accessible with a few mouse clicks, aalyzable by age, geder, ethicity, geographic locale, ad employmet status. But there is much we do ot kow How may people i the US are i recovery? How did they get there? Treatmet ca be effective, eve though it typically requires multiple episodes of care uder the curret service model, but rates of reoccurrece are high eve after several years. Less tha oe-third of people with drug or alcohol problems ever seek treatmet. How do we sell treatmet to those who eed it? Medicatios that ca help achieve (ad maitai?) abstiece are curretly available or i developmet ad testig phases to address depedece o a growig umber of substaces. The goal of these medicatios is primary symptom maagemet. ARE WE CURING ADDICTION? Addictio is best coceptualized as a chroic brai disorder. As such, it caot be cured but it ca be maaged. Comparig addictio to other chroic coditios such as diabetes, hypertesio or asthma, McLella (2002) oted the may similarities i the etiology, course, treatmet ad treatmet outcomes across chroic coditios. However, more tha (or perhaps ulike) ay other chroic coditio, active addictio has deleterious cosequeces o almost all areas of fuctioig (physical ad metal health, family ad social fuctioig, employmet ad educatio, housig, legal status, ad overall well-beig). Abstiece from drugs ad alcohol is likely a prerequisite to improvemet i other life domais, but it rarely brigs istat relief (Vaillat, 1995). Addicted idividuals who address abstiece aloe are ulikely to maitai that abstiece for a prologed period. Idividuals eed to address recovery i the multiple life domais affected by active addictio. Note: For may, the term recovery used to deote regaiig somethig that was lost, is a misomer as relates to exterals (materials possessios or status). Rather, a recurrig theme amog persos i recovery is that what is regaied is a idetity (a self) ad a potetial that were lost to addictio (Laudet, 2007). Ulike other chroic coditios, focusig oly o the pathology of addictio (symptoms) leads to stigma that traslates ito discrimiatory policies agaist those who have overcome the disease ad represets may obstacles to rebuildig lives such as i housig, educatio, labor markets, etc. May idividuals emerge from active addictio with co-occurrig metal or physical health coditios that also carry stigma (most otably metal health issues ad HIV/AIDS). May idividuals who have overcome active addictio experiece edurig shame ad guilt about the impact their past substace use had o loved oes ad o society. This may result i spiritual malaise, depressio, ad related egative emotios that ca hider recovery. These secodary symptoms of active addictio must be addressed as part of the recovery process. Would a diabetic experiece relief from his/her coditio by udertakig a searchig fearless moral ivetory (4th step)? Would a hypertesive cosider the eed to make ameds (9th step) for actios take whe s/he was symptomatic? Yet, may idividuals i recovery from addictio worldwide do so i the cotext of workig the 12-step recovery program. Thus, while addictio shares may 5

8 characteristics with other chroic coditios, it also has a umber of uique features that require attetio whe seekig to elucidate ad promote stable remissio (recovery). The World Health Orgaizatio defies health as a resource for everyday life rather tha as the mere absece of symptoms (World Health Orgaizatio, 1986). I a iterview with Bill White, Dr. Clark recetly stated that Recovery is more tha abstiece from alcohol ad drugs; it is about buildig a full ad productive life i the commuity. Our treatmet systems must reflect ad help people achieve this broader uderstadig of recovery (Clark, 2007). The call is beig heard. State by state, substace use disorder services atiowide are udergoig a historic trasformatio from the prevalet acute care model to a perso-cetered, multi-system, cotiuum of WELLNESS-orieted care: recovery-orieted systems of care (ROSC). Though this is begiig to chage (e.g., Betty Ford Istitute; Betty Ford Istitute Cosesus Pael, 2007), the costruct of recovery has yet to be adequately defied, decostructed, ad operatioalized. Log-term recovery is virtually ucharted territory. How ca we effectively promote somethig we poorly uderstad ad have ot adequately examied? THUS THE FIRST STEP OF THE ACTION PLAN TO PROMOTE LONG-TERM RECOVERY MUST BE TO DETERMINE WHAT WE NEED TO KNOW AND TO SEEK ANSWERS. WHAT DO WE NEED TO KNOW? What is recovery? Specifically what are the required igrediets: abstiece PLUS WHAT? I which domais is improvemet required for there to be recovery ot oly i the eyes of society but also for the idividual? Relatedly, there is prelimiary evidece that quality of life satisfactio prospectively predicts sustaied abstiece by maitaiig motivatio (Laudet, Becker, & White, 2008). What costitutes a satisfyig quality of life i recovery? How does that chage over time? For idividuals to achieve log-term recovery, they eed to iitiate recovery. May idividuals with severe problems require multiple attempts before truly iitiatig the recovery process. What eeds to click i the perso? What is the catalyst? How ca professioals (both traditioal treatmet providers ad providers of o-traditioal support services) shorte the typical addictio career? For recovery to become log-term, early recovery has to be sustaied ad solidified. How do we egage the commuity ad other o-specialty care providers (e.g., primary care physicias) i becomig early iterveers to prevet retur to active addictio or other life loss that may precipitate relapse? Research shows differeces i depedece ad cessatio trajectories across drug classes (Office of Applied Studies, Substace Abuse ad Metal Health Services Admiistratio, 2008); What are the implicatios of these fidigs for recoveryorieted services, specialty care, recovery outcomes, patters ad determiats? The risk of retur to active addictio becomes miimal after 5 or more years of abstiece. What else eeds to happe for idividuals to achieve ad sustai recovery? What is log-term recovery? What degree of improvemet i which life domais are required for the idividual to have somethig s/he does ot wat to lose to active substace use? Multiple paths to recovery How do people recover? What works? For whom? Whe? Uder which circumstaces (low/high recovery capital, severity, family history, etc.)? Not oly to iitiate recovery but also to sustai it over five years, te years, or for life? Though participatio i treatmet ad 12-step fellowship programs appear effective for some, may do ot participate i either ad reoccurrece rates are high eve amog those who do participate. Further research is eeded o atural recovery, religious ad spiritual recovery, secular recovery with ad without the assistace of mutual aid ivolvemet ad/or professioal treatmet that may iclude medicatios, the use of recovery homes, recovery coaches ad other emergig forms of recovery maagemet. Through the multiple pathways available, what are the commo themes i recovery? How effective ad cost effective are recovery-orieted systems of care (ROSC) i terms of lives ad dollars saved, commuities restored, families reuited, employmet rates icreased (or abseteeism decreased) ad demostratio of good citizeship livig up to the resposibilities of society? This eeds to be measured usig a logitudial approach across isolated episodes of specialty care. It is likely that while ROSC represets a greater ivestmet tha a idividual treatmet episode, the approach will save moey ad lives whe evaluated over the life of a idividual s service career. 6

9 What is the most effective role of peers i recovery services? How is recovery from addictio similar to ad differet from recovery from other chroic coditios? From medical coditios (e.g., diabetes ad arthritis)? From metal health coditios (e.g., depressio ad PTSD)? From recovery from other addictios (e.g., iteret, gamblig, food, sex, ad shoppig)? What ca we lear from other fields, ad, specifically, for which aspect of addictio recovery must we devise specific itervetios, paradigms, ad/or measures? There is a high rate of co-occurrig physical ad metal health chroic coditios; to date the addictios field has focused almost exclusively o psychiatric comorbidity ad o HIV. How do other co-morbid chroic coditios affect the iitiatio ad maiteace of recovery? How do we itegrate the multiple systems of care that are required to support welless for persos with multiple coditios? How do we dissemiate the message of hope ad icrease the attractiveess of recovery services? WHAT WILL THE SCIENCE OF RECOVERY TELL US THAT WE DO NOT ALREADY KNOW? Before askig what the sciece of recovery will tell us, we must first commit to makig the sciece of recovery a true sciece. The research questios ad methods may differ, but the same high scietific stadards must be upheld so that the sciece of recovery is as good (or better) as the sciece of addictio. The ultimate goal of sciece is to iform cliical practice to improve lives. The sciece of addictio has ad will cotiue to elucidate the problem (the multiple causes of substace use disorders) ad to iform strategies to address it. We have a solid uderstadig of why ad how people become substace depedet (e.g., brai studies ad biology) that is beig traslated ito therapies to lead substace depedet persos out of addictio. The sciece of recovery will complemet the sciece of addictio ad lead to additioal, diverse effective strategies to promote healthy, satisfyig, productive lives amog formerly depedet idividuals. The sciece of recovery will iform the recovery commuity as well as service developmet, policy ad fudig ad make sigificat cotributios to our atio s health ad its ecoomy. The mere actio of makig welless a boa fide outcome will help reiforce the fact that recovery from addictio ca be ad is a reality for may. By extesio, this ca give hope to the may idividuals ad families affected by substace use disorders ad support them i their search for the solutio that will work for them. Empirically-derived kowledge about recovery as a multi-dimesioal, dyamic costruct will provide cliicias, the recovery commuity, ad other stakeholders with realistic expectatios ad goals. It will iform the developmet of tools to measure recovery ad idetify recovery milestoes. This will help track chage over time (ot oly i terms of abstiece but also i terms of global fuctioig), iform chagig service/support eeds as the process ufolds, help payers ad prospective cliets to select ad evaluate services, ad facilitate research to quatify the effectiveess ad cost-effectiveess of recoveryfocused services. Idetifyig the beefits of recovery, ot oly to society but also to the idividual, makes recovery-orieted substace abuse services more attractive tha those sellig abstiece aloe. This ca cotribute to icreased help-seekig amog persos with alcohol ad other drug problems, ad ca ultimately traslate ito miimizig the may costs of active addictio-quatifiable costs such as those for healthcare, crime, ifectious diseases ad other medical cosequeces of addictio, loss of productivity, ad less easily quatifiable costs related to families, childre, ad commuities. Empirically-derived kowledge about the pheomeology of log-term recovery (e.g., whe is recovery stable? sustaied?) will cotribute to miimizig may of the curret societal barriers to recovery. As metioed above, these barriers ted to maifest themselves as discrimiatig policies ad pervasive stigma attached to persos who have a history of addictio related to quality of life issues such as employmet, housig, ad professioal licesures. The sciece of recovery will allow us to quatify the likelihood of recovery from substace use disorders regardless of path, ad to idetify factors that promote ad hider the process. By learig how recovery is attaied ad sustaied, iformatio will emerge about the various paths to recovery (professioal treatmet, self help, religious ad spiritual recovery, ad others perhaps yet uidetified), help determie whether specific paths are idicated for certai groups of idividuals ad idividuals themselves (depedig o severity, substace, geder, comorbidity, recovery or social capital ). That will provide helpig 7

10 professioals ad persos experiecig substace use disorders a meu of recovery paths from which to choose i the same way physicias ad their patiets ca review ad select amog strategies to address high cholesterol depedig o the idividuals blood levels, medical ad family history, ad lifestyle. Idetifyig the critical igrediets of recovery at successive stages of the process will iform recovery orieted systems of care, a service model that is likely to be more cost effective tha the prevalet acute-care paradigm. Quatifyig its effectiveess ad cost effectiveess require recovery criteria that do ot curretly exist. CURRENT BARRIERS TO THE SCIENCE OF RECOVERY I structure ad focus, addictio research fudig thus far has mirrored the acute-care model prevalet i cliical practice. This approach is ill-suited to elucidatig recovery from a chroic coditio. Further, we have looked to other biomedical disciplies for scietific stadards, at times compromisig exteral validity ( real world relevace ) i the process. These strategies are well-suited to address some questios ad have yielded great advaces e.g., treatmet effectiveess studies but are ill-suited to study recovery. Key obstacles to coductig (or rather securig fudig for) recovery-orieted research curretly iclude: Primary focus o symptoms (substace use) ad social (public health ad safety) which lead to isufficiet attetio o welless (e.g., quality of life ad global health) Primary emphasis o the biomedical aspects of addictio (e.g., brai studies ad medicatio studies) to the detrimet of ivestigatig other critical determiats of remissio ad recovery (e.g., psychosocial ad socio-cultural eviromet i addictio ad recovery patters) i a itegrated maer. Emphasis o formal treatmet services which lead to isufficiet attetio o the atural history of recovery usig various paths; the psychosocial eviromet; social, persoal ad social capital; socio-cultural resources ad obstacles; ad family history ad commuity iflueces o patters of substace use, paths ad patters of recovery. Isufficiet log-term studies which lead to emphasis o the iitiatio of abstiece rather tha o promotio of sustaied welless (i.e., log term recovery). Most recetly: Fiscal austerity favorig shorter studies or large cliical trials of therapeutic itervetios to the detrimet of log-term observatioal studies ( atural history ) that hold great promise to idetify paths, patters ad determiats of the broader costruct of recovery. 8

11 FUTURE DIRECTIONS Services for people with substace use disorders are gradually becomig more recovery-orieted ad makig two sigificat paradigmatic shifts: (1) From the acute, itese episode of specialty care model to a cotiuum of multisystem care, ad (2) from addressig primary symptoms to promotig global health. If addictio is to be studied as a chroic relapsig disease, icreased follow-up periods will be ecessary to advace our uderstadig for achievig ad sustaiig recovery. Advacig sciece i this area will require comprehesive, idividually based, logitudial data sets (Hilto, Chadler, & Compto, 2008: 5). What research fudig agecies ca do to promote log-term recovery: Iclude recovery as a boa fide topic ad major goal area i agecies strategic plas Recovery ca o loger be treated as a secodary outcome or as merely abstiece from drugs ad alcohol. Earmark research fudig (RFA) specifically to elucidate the pheomeology (igrediets) of recovery ad log-term recovery processes, patters ad their determiats: Solicit research that: Adopts a logitudial, aturalistic, developmetal, career perspective (a la Vaillat, Hser, ad Moos/Timko). Cosiders the multiple paths to recovery-ot just treatmet. Combies quatitative ad qualitative methods to gai i-depth kowledge FROM (ad about) persos i recovery. Makes welless (recovery ad global fuctioig), NOT substace use, crimial ivolvemet ad employmet oly, THE primary outcome. Adopt a ecologically valid perso i eviromet approach rather tha a idividual-level approach oly. Addresses research questios developed i partership with service providers (to maximize techology trasfer) ad with the recovery commuity (to maximize relevace). 9

12 APPENDIX 1: RECOVERY SYMPOSIUM DAY 2 AGENDA Time Evet / Topic / Title ad Speakers 7:30 AM - 8:00 AM Registratio 8:00 AM - 8:15 AM Welcome Dr. Michael Flaherty - Executive Director, IRETA ad Priciple Ivestigator, NeATTC Mr. Jim Baker - Chairma, Philadelphia Mayor s Drug ad Alcohol Commissio Mr. Gilbert Gadso - NET Cosumer Coucil 8:15 AM - 9:15 AM Symposium Keyote Ms. Deb Beck - Presidet/Drug ad Alcohol Service Providers Orgaizatio of Pesylvaia, Member ad Policy Co-Chair, State Associatios of Addictio Services Cosultat Recovery A Systems Perspective 9:15 AM - 10:45 AM Symposium Pael 10:45 AM - 11:00 AM Break 11:00 AM - 12:00 PM Symposium Pael Mr. William White - Seior Researcher, Chestut Health Systems Lighthouse Istitute Recovery Orieted Systems of Care - Perspectives from Cities ad States Dr. George DeLeo (Moderator) - Director, Ceter for Therapeutic Commuity Research, Natioal Developmet ad Research Istitutes, Ic. Dr. Thomas Kirk - Commissioer, Coecticut Departmet of Metal Health ad Addictio Services Mr. Phillip Valetie - Executive Director, Coecticut Commuity for Addictio Recovery Dr. Arthur Evas - Director, Philadelphia Dept. of Behavioral Health & Metal Retardatio Services Ms. Beverly Haberle - Executive Director, Bucks Couty Coucil o Alcoholism ad Drug Depedece, Ic. Ms. Kare Carpeter-Palumbo - Commissioer, NY State Office of Alcoholism ad Substace Abuse Services Ms. Betty Currier - Cosultat, Coucil o Addictios of New York State Aligig Special Populatio Needs with Recovery Orieted Systems of Care Ms. Cheryl Floyd (Moderator) - Executive Director, Pesylvaia Recovery Orgaizatios Alliace Ms. Tig-Fu May Lai - Director, Program Developmet ad Quality Assurace of Behavioral Health Services of Hamilto Madiso House Mr. Harla Prude - Co-Fouder ad Coucil Member of the NorthEast Two-Spirit Society Ms. Lisa Mojer-Torres, Esq. - New Jersey Cosumer Advocate Dr. Calvi Tret - Detroit Health Departmet, Bureau of Substace Abuse 10

13 12:05 PM - 1:20 PM Luch / Keyote Presetatio 1:25 PM - 2:05 PM Respodet Pael 2:05 PM - 2:20 PM Break A Model for Recovery Orieted Systems of Care from a Natioal Perspective Dr. H. Westley Clark - Director, Ceter for Substace Abuse Treatmet, Substace Abuse ad Metal Health Services Admiistratio Commets o A Model for Recovery Orieted Systems of Care from a Natioal Perspective Mr. Joh J. Coppola (Moderator) - Executive Director, Alcoholism & Substace Abuse Providers o New York State, Ic., ad Represetative of State Associatios of Addictio Services Ms. Melody Heaps - Fouder ad Presidet, Treatmet Alteratives for Safe Commuities Mr. Mark Parrio - Presidet, America Associatio for the Treatmet of Opioid Depedece Dr. Keeth Ramsey - Presidet ad CEO, Gateway Rehabilitatio Ceter Ms. Pat Taylor - Executive Director, Faces & Voices of Recovery 2:20 PM - 2:30 PM Itroductio for Research Focus Research ad Recovery Dr. Robert Forma - Cliical Scietist, Alkermes, Ic. 2:30 PM - 2:55 PM Symposium Presetatio Buildig the Sciece of Recovery: A Recovery Research Ageda Dr. Alexadre Laudet - Director, Ceter for the Study of Addictios ad Recovery, Natioal Developmet ad Research Istitutes, Ic. 3:00 PM - 3:25 PM Symposium Commetary Commets o a Recovery Research Ageda 3:30 PM - 3:55 PM Symposium Commetary Dr. Tim Codo - Deputy Director, Natioal Istitute o Drug Abuse Commets o a Recovery Research Ageda Dr. Mark Willebrig - Director, Divisio of Treatmet ad Recovery Research, Natioal Istitute o Alcohol Abuse ad Alcoholism 4:00 PM - 4:25 PM Symposium Commetary Commets o a Recovery Research Ageda 4:30 PM - 4:50 PM Symposium Summatio Dr. A. Thomas McLella - CEO, Treatmet Research Istitute Where Do We Go From Here? 4:50 PM - 5:00 PM Evaluatio ad Adjour Dr. Michael Flaherty - Executive Director, IRETA ad Priciple Ivestigator, NeATTC Ms. Loetta Albright - Director, Great Lakes Addictio Techology Trasfer Ceter 11

14 APPENDIX 2: COMPILATION OF RECOVERY-FOCUSED QUESTIONS ACHIEVING CONSENSUS ON A DEFINITION OF RECOVERY Whe recovery is successful (ad that eeds to be defied), what actually chages? What is gaied (i which life domais are the chages)? Is aythig of value lost o the way to recovery? What are the behavioral ecoomics of recovery (gai vs. loss)? What are the critical igrediets/required elemets of sustaied recovery? I terms of substace use AND global health, i.e., other key fuctioig/life areas metal health; physical health; social/ family; employmet/fiaces; livig coditios; access to care; leisure/recreatio; spirituality; ad what else? This eeds to be examied across subpopulatios, primary substaces, ad by recovery stages, amog others. DESCRIBING THE RECOVERY PROCESS What is the pheomeology of recovery over time What chages? How does it chage? What is the relatioship amog the critical life domais Are they idepedet? Are they cumulative? Is abstiece i additio to a fatastic family life, mediocre health ad o job as predictive of sustaied recovery as abstiece plus a mediocre family life ad a mediocre job? What is the absolute ad relative importace of each of the life domais/compoets: To the idividual (importace ratigs)? To predictig recovery maiteace? e.g., (a) Is abstiece critical to iitiate chage i the other domais or vice versa?; (b) is log term abstiece (say 3 years) i the absece of other positive chages eough to sustai recovery or are such persos at icreased risks for relapse relative to someoe with the same abstiece duratio plus positive chages i global fuctioig? (i.e., is abstiece eough?) Do the relatioships ad rakigs of multiple life domais chage over time? For example, the first few moths oe may really ejoy wakig up with a clear head or regaiig the trust of family members. The oe wats a job, social relatioships, a larger house, a sese of purpose, etc. At that stage, does absece of desired/eeded chage icrease the risk of retur to substace use? Coversely, what is the pheomeology of loss/deterioratio i these domais? Does deterioratio i key life domais (e.g., metal health or social fuctioig) lead to loss of abstiece or is abstiece lost first? Does that vary by geder, age, ethic subgroup, or recovery stage? Could we use this iformatio to develop a more attractive recovery sales package to various subgroups? How would sellig welless rather tha abstiece ifluece service utilizatio ad, ultimately, the atio s health? Is there a poit of o retur to active addictio/depedece where the odds of retur to active use are essetially zero or is it really oce a addict always a addict? If there is a poit of o retur, what is the set of criteria (e.g., a give duratio of cotiuous abstiece plus a give level of fuctioig i key domais) that allows us to predict ad promote arrivig at that poit? This speaks to whether depedece/addictio is a lifelog illess (ad restorig ay rights or privileges, professioal or otherwise, to persos with a depedece history). DESCRIBING THE RECOVERY PROCESS: Chroology What is log-term recovery specifically how log or does it vary ad, if so, accordig to what? What are the stages of recovery? What are the importat milestoes i recovery? What are typical logitudial patters of recovery, ad what are the critical poits whe people are vulerable to relapse e.g., late-stage relapse-after multiple years of abstiece? 12

15 BENEFITS ad ECONOMICS of RECOVERY What are the psychosocial, medical, ad euro-cogitive chages (improvemets) that result from sustaied abstiece? For the commuity ad for society at large, what are the beefits of promotig log-term recovery i terms of fiacial cost savigs (specialty care, other social services, crimial justice system); public health ad safety (crime ad ifectious disease trasmissio); productivity/ employmet; family/commuity health; ad civic participatio? How do we use this iformatio to sell treatmet ad promote welless? How does that compare to the curret care model? MEASURING RECOVERY beyod abstiece Review existig measures (e.g. Quality of Life) ad idetify or develop a welless-based comprehesive, multi-dimesioal, psychometrically soud measure of recovery that icorporates all relevat life domais, is sesitive to chage, ad meaigful to the recovery commuity. For recovery-orieted systems of care, such a measure is ecessary for exteral accoutability purposes as well as for iteral quality assurace ad moitorig, ad to guide service developmet ad plaig. RECOVERY PATHS What are the various paths used to iitiate ad sustai recovery? These may iclude but are ot limited to: Natural recovery (o use of professioal services or self-help) Differet modalities ad models of professioal/specialty services (aloe or i combiatio with 12-step or other mutual aid). This icludes psychosocial ad pharmacotherapy. 12-step (aloe or i combiatio with specialty care) No 12-step mutual aid/self help (e.g., Secular Orgaizatio for Sobriety) Culture-specific approaches (e.g., Wellbriety/White Biso) Religio ad spirituality Alterative methods (aloe or i combiatio with ay of the above). This may iclude acupucture, hyposis, yoga, ad meditatio. Are determiats (factors that promote ad/or hider) of recovery iitiatio ad maiteace-promotig similar or differet? How ca this best be traslated ito recovery-orieted systems? If determiats differ by recovery stage (milestoe), at which poit i the process do recovery support service eeds chage to maximize sustaied recovery? Give the desire to quit usig, why ad how does someoe select a give path? What is the prevalece of differet pathways out of addictio? Which path is more effective at egagig someoe ad achievig early recovery (iitiatio) give the perso s idividual, cliical, or other characteristics? Which path is more attractive to ad effective for goig from early to itermediate or sustaied recovery? Assumig each of the paths promotes abstiece, do they automatically produce icreases i the other compoets (global fuctioig)? Is abstiece pheomeologically ad euro-cogitively the same regardless of path e.g., volutary, medicatioassisted, ad forced abstiece (cotrolled eviromet)? Give a equal duratio of various paths, what is the prospective effectiveess of each (or combiatio thereof) to lead to sustai cotiued abstiece ad global fuctioig? Is there a optimal combiatio amog complemetary paths, e.g., professioal treatmet to iitiate recovery i additio to 12-step participatio both durig treatmet ad as aftercare? 13

16 Do specific paths/combiatios work best for specific groups of idividuals (by severity, pre-recovery capital, geder, etc.)? Compare/cotrast the pheomeology ad logitudial patters of recovery across various pathways,. e.g., with ad without active 12-step ivolvemet ad/or a spiritual foudatio. Ca we idetify a typology of recovery styles that ca guide idividual-level recommedatios to maximize the attractiveess of recovery, e.g., ot everyoe wats to be a 12-stepper. This may be a issue of recovery culture. SPECIFIC SERVICES/RECOVERY RESOURCES PROFESSIONAL TREATMENT/SPECIALTY CARE 12-STEP Is specialty care ecessary? For whom? Which level of care? The what? How ca we best idetify whe/how to move cliets from differet levels of care (residetial to IOP, IOP to OP) to keep people egaged i the chage process? Participatio i treatmet ca ehace protective resources (e.g., family support, goal directio, moitorig, fried ad peer orms ad models, ad rewardig activities) that sustai recovery (Moos & Moos, 2007). How ca this be promoted systematically? What are the critical active igrediets of 12-step participatio (meetig attedace ad ivolvemet such as workig the steps or doig service) at successive stages of recovery? Decostructig the 12-steps: What are the processes uderlyig the ifluece of each of these igrediets o abstiece (iitiatio ad maiteace) ad o global health ad fuctioig? Is there a 12-stepper profile? What are the cliical, recovery capital, ad demographics of persos who beefit from 12-step? (These issues have bee ivestigated most amog alcohol-depedet persos. Do fidigs geeralize to drug-depedet persos as well?) Ulike professioal treatmet that is ofte evaluated moths after services ed (e.g., 6 moths post discharge outcome data), most studies o 12-step are coducted amog idividuals who are curretly participatig (performace data). What is the effectiveess of 12-step i sustaiig abstiece ad the other compoets of recovery after someoe stops goig (outcome)? Does 12-step stay with you after you stop goig? Specifically what stays with you? Ca we bottle this for persos who choose ot to go to 12-step? OTHER SELF-HELP/MUTUAL AID Ivetory of o 12-step addictio recovery support groups What are the reasos for participatio i o 12-step groups istead of 12-step groups? What are the beefits derived? Are they differet tha beefits derived from 12-step groups? Is there a certai type of idividual attracted to these groups (to iform meu of recovery optios)? What is the effectiveess of other self-help/mutual aid orgaizatios? What are the uderlyig mechaisms of actio for o 12-step groups? Are they differet tha 12-step groups? (what are the uiversals of recovery support groups? What is specific to each? For whom is each best idicated?) PEER RECOVERY SUPPORT SERVICES (PRSS) AND RECOVERY SUPPORT SERVICES (RSS) What is the effectiveess of each at promotig etry ito treatmet (whe idicated), abstiece, ad global health? What is the effectiveess of each i keepig people egaged i the chage process? Coduct cliical trials comparig PRSS ad RSS vs. stadard treatmet. What is the cost effectiveess of PRSS ad RSS compared to stadard treatmet? Are PRSS ad RSS really differet? (does peeress matter?) Are PRSS ad RSS more or less effective whe they are offered i treatmet ceters? 14

17 What strategies are most successful i likig idividuals leavig treatmet (commuity-based or i jail/priso) to recovery commuity resources, icludig recovery support services? OTHER What is the effectiveess ad cost effectiveess of participatio i recovery commuity istitutios (e.g., recovery homes, recovery schools, recovery idustries, recovery support ceters, recovery miistries/churches) i ehacig log-term recovery? What is the potetial of ew techologies to support idividual recovery aloe or i combiatio with specialty care or other services? For example, telephoe or web-based recovery coaches, olie support groups, recovery support text messages. What is feasible? For whom? What is the effectiveess ad cost-effectiveess of these techologies? RECOVERY-ORIENTED SYSTEM OF CARE (ROSC): SERVICE DEVELOPMENT AND FUNDING What eeds to happe to trasitio from the acute-care model to a recovery-orieted system of care (ROSC) at the system level (e.g. statewide)? At the program level? Withi the paymet system (reimbursemet structures)? At the cliical level as impacts services from cliicias ad other service providers to idividuals? What do service developers eed to kow to move a recovery-orieted system of care forward? How do we implemet ad sell a recovery-orieted system of care i the curret beleaguered ad deficit-focused system of care? What ca the substace use disorder treatmet field lear from the metal health field ad other fields addressig chroic coditios about recovery-based care (welless promotio)? How does the effectiveess ad cost-effectiveess of ROSC compare to the prevalet acute-care model? Specifically what traiig do staff (program directors, couselors, others) eed to trasitio to a recovery-orieted cotiuum of care without alieatig them by implyig that what they have bee doig may ot be workig as well as we hoped? Ca this traiig be streamlied (e.g., web-based) for ehaced efficiecy? What is the feasibility ad effectiveess of buildig performace-cotractig ito ROSC (assumig we arrive at recovery measure ad criteria)? MULTISYSTEMS/SERVICE INTEGRATION What is the best way to coordiate the provisio of a spectrum of acillary services (housig, legal problems, etc.) with specialty care to provide a truly perso-cetered system that promotes ad sustais log term recovery? What is the best way to itegrate professioal services (specialty care, social services, etc.) with the use of peers ad voluteers? How ca we foster the creatio of multi-agecy, multi-discipliary service teams? What are the systemic barriers to flexible systems that ca accommodate the chagig eeds as recovery progresses? Ca we lear from other systems or fields that have idetified ad successfully effected service itegratio e.g., metal health, disabilities? RECOVERY RESOURCES (other tha paths) AND OBSTACLES Resources ad obstacles ca be withi ad/or outside of the idividual Psychosocial resources are ofte ivestigated but ot i a itegrated fashio (e.g., cogitios, social eviromet ad support, spirituality/faith) Obstacles ca iclude characteristics of the idividual, his or her sociocultural eviromet, as well as policies 15

18 Key questios: Does the idividual believe recovery is attaiable? Are there successful role models (idividuals i recovery or persos who do ot have a substace abuse problem) i the immediate eviromet ad i the prevalet culture (e.g., media)? What are the factors that promote ad hider the iitiatio ad maiteace of log-term recovery? How do they iteract at various stages ad for differet populatios (e.g., high/low severity, recovery capital etc.)? At ay give recovery stage (early, itermediate, or sustaied), what is the power (explaatory value) of each domai to predict recovery, ad how do they iteract (is there a cumulative effect?) Are factors promotig/hiderig iitiatio ad maiteace the same or differet? If differet, how do they differ, ad what services ad other support are eeded for iitiatio ad maiteace? What is the role of family i the idividual recovery process? What are the stages (ad eeds) of family recovery? Do stigma ad discrimiatio hider recovery iitiatio? Recovery maiteace? How so? What policy chages are eeded? SPECIAL POPULATIONS ad SOCIOCULTURAL ISSUES Where feasible, the key questios addressed i a comprehesive recovery-focused research ageda must be cosidered for large subgroups to determie where differeces ad similarities lie. This will guide policy ad services. Subgroups iclude but are ot limited to: Youth, wome, Native Americas, Latios, dually-diagosed (co-occurrig), people i medically-assisted recovery, veteras, older (over 50!), rural populatios, ex-offeders, icarcerated idividuals, trauma survivors, persos who are HIV+ ad/or HepC+, persos with multiple depedeces or addictios (e.g., substace use ad gamblig or food). Idetify cross-cultural as well as culture-specific patters ad processes of log term remissio as a fuctio of differet socio-political ad service delivery cotexts. Stated differetly: what is the role of the sociopolitical cotext i how recovery is coceptualized, sought, attaied ad experieced? DISSEMINATING THE MESSAGE OF HOPE/PROMOTING RECOVERY: HOW DO WE SELL RECOVERY? How may people i the US are i recovery (assumig we have a defiitio)? How may are i log-term recovery? (this would give the recovery movemet a costituecy to advocate for services, fudig ad policy chage.) How do we dissemiate the message that log-term recovery is attaiable ad there are multiple paths to achieve it? Are there ways to thik about the styles of recovery (idetity ad relatioal patters) that will ecourage more idividuals to seek ad sustai their recovery give that curret treatmet is ot attractive to may who eed it? What are effective ways/veues to commuicate with people eedig/seekig recovery, to egage ad sustai them i that pursuit? What sells recovery? What sells treatmet? Clearly the promise of abstiece is ot eough. What are effective ways to commuicate with people about how to evaluate ad use iformatio about pathways to recovery to make iformed choices? What role does the media portrayal of people with addictio problems ad the coverage of addictio issues have i ecouragig (or ot) people to seek ad sustai their recovery? 16

19 Referece List Betty Ford Istitute Cosesus Pael. (2007). What is recovery? A workig defiitio from the Betty Ford Istitute. Joural of Substace Abuse Treatmet, 33(3), Clark, W. (2007). Recovery as a orgaizig cocept. Retrieved February 7, 2008 from With%20H.%20Westley%20Clark,%20MD,%20JD,%20MPH,%20CAS,%20FASAM.pdf Commowealth Fud, The. (2002). Five-atio survey: US adults least satisfied with health system. The Commowealth Fud Quarterly, 8(1), Deis, M.L., Scott, C.K., & Fuk, R. (2003). A experimetal evaluatio of recovery maagemet checkups (RMC) for people with chroic substace use disorders. Evaluatio ad Program Plaig, 26(3), Fioretie, R. & Hillhouse, M. (2000). Drug treatmet ad 12-step program participatio: The additive effects of itegrated recovery activities. Joural of Substace Abuse Treatmet, 18(1), Flaherty, M.T. (2006). A uified visio for the prevetio ad maagemet of substace use disorders: Buildig resiliecy, welless ad recovery a sift from a acute care to a sustaied care recovery maagemet model. Pittsburgh, PA: Istitute for Research, Educatio ad traiig i Addictios. Hilto, T.F., Chadler, R.K., & Compto, W.M. (2008). Needed: logitudial research that ca iform dyamic models for the treatmet of addictio as a disease. Evaluatio Review, 32, 3-6. Istitute of Medicie. (2001). Crossig the quality chasm: A ew health system for the 21st cetury. Washigto, DC: Natioal Academy Press. Laudet, A.B. (2007). What does recovery mea to you? Lessos from the recovery experiece for research ad practice. Joural of Substace Abuse Treatmet, 33, Laudet, A., Becker, J., & White, W. (2008). Do t waa go through that madess o more: Quality of life satisfactio as predictor of sustaied substace use remissio. Substace Use ad Misuse (i Press). McKay, J.R. (2005). Is there a case for exteded itervetios for alcohol ad drug use disorders? Addictio, 100(11), McLella, A.T. (2002). Is addictio a illess? Ca it be treated? I Haack, M.E.R. & Adger, Jr., H. (Eds.), Strategic Pla for Iterdiscipliary Faculty Developmet: Armig the Natio s Health Professioal Workforce for a New Approach to Substace Use Disorders. Providece, RI: Associatio for Medical Educatio ad Research i Substace Abuse, pp Moos, R. & Moos, B. (2005). Paths of etry ito alcoholics aoymous: Cosequeces for participatio ad remissio. Alcoholism: Cliical & Experimetal Research, 29(10), Moos, R.H. & Moos, B.S. (2007). Protective resources ad log-term recovery from alcohol use disorders. Drug ad Alcohol Depedece, 86, Office of Applied Studies, Substace Abuse ad Metal Health Services Admiistratio. (2008). The NSDUH Report: Substace Use ad Depedece Followig Iitiatio of Alcohol or Illicit Drug Use. Rockville, MD: SAMHSA. Retrieved o November 18, 2008 from Scott, C.K., Foss, M.A., & Deis, M.L. (2005). Pathways i the relapse-treatmet-recovery cycle over 3 years. Joural of Substace Abuse Treatmet, 28(Supplemet1), S63-S72. Vaillat, G.E. (1995). The Natural History of Alcoholism Revisited. Cambridge, MA: Harvard Uiversity Press. White, W. (2008). Recovery Maagemet ad Recovery-Orieted Systems of Care: Scietific Ratioale ad Promisig Practices. Pittsburgh, PA: Northeast Addictio Techology Trasfer Ceter. White, W. & Kurtz, E. (2006). Likig addictio treatmet ad commuities of recovery: A primer for addictio couselors ad recovery coaches. Pittsburgh, PA: Northeast Addictio Techology Trasfer Ceter. World Health Orgaizatio Europea Regioal Office. (1986). Copehage, Demark: WHO. 17

20 HMark 6.5x9 BW Highmark:Layout 1 8/28/08 3:34 PM Page 1 COMMUNITY IS SOMETHING WE ALL CELEBRATE. A healthy commuity supports families ad idividuals i makig the most of their lives. At Highmark, we believe i stregtheig commuities through programs ad services that help people live loger, healthier lives. Programs promotig health ad welless, ijury ad disease prevetio, ad eve ecoomic ad commuity developmet. Ad by ecouragig our may geerous employees who devote coutless hours to commuity service. Because whe people choose to ivest i their commuity, that s cause for celebratio. A Idepedet Licesee of the Blue Cross ad Blue Shield Associatio 18

21 We are pleased to support your efforts to improve our commuity s health. 650 Smithfield Street, Ceter City Tower, suite 2400 Pittsburgh, PA Recovery Maagemet ad Recovery-orieted Systems of Care: Scietific Ratioale ad Promisig Practices William L. White, MA Seior Research Cosultat Chestut Health Systems NEW Istitute for Research, Educatio ad Traiig i Addictios IRETA 425 Sixth Aveue, Suite 1710 Pittsburgh, PA Pioeerig ew Moographs available for dow-load or i prit. Visit org ad Add these vital publicatios to your library. 19