Once the problem of addiction is recognized, individuals can begin the process of recovery by following a treatment plan. Recovery is the process of overcoming both physical and psychological dependence on a psychoactive drug, with a commitment to sobriety.

What is the difference between treatment and recovery?

Treatment and recovery are interconnected, but not the same. As the NIDA Principles of Drug Addiction indicate, treatment is an important component to the recovery process.

According to the Center for Substance Abuse Treatment (CSAT), “treatment” is defined as in- or outpatient services that focus on initiating and maintaining an individual’s recovery from alcohol or drug abuse and on preventing relapse. Treatment can include detoxification, group or individual counseling, rehabilitation and the use of methadone or other prescription medications. It also can involve drug or alcohol education and self-help groups, such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA). Quite often, treatment is considered the “light at the end of the tunnel” for those afflicted with substance abuse addiction. Unlike addiction itself, treatment is a positive process, involving a variety of support systems that systematically help lead individuals to successful, fulfilling lives without drugs and/or alcohol.

Individuals who have participated and completed treatment programs are considered to be “in recovery.” Thus, recovery is recognized as “…an ongoing process of improvement–biologically, psychologically, socially and spiritually–while attempting to maintain abstinence from alcohol and other drugs.” (Strawn, Julie, WIN, “Substance Abuse Welfare Reform Policy,” Issue Notes, Vol. 1, No. 1, 1/7/97. p.3) Furthermore, individuals can be forced into treatment, but cannot be forced into recovery. Recovery from alcohol and other drug abuse is a voluntary process, and a strategy to reach recovery should include treatment. Therefore, treatment is not a long-term solution to alcohol and other drug addiction, but a commitment to recovery is. In addition, some people become “clean and sober” solely through continuous participation in 12-step programs, instead of through treatment. They, too, consider themselves “in recovery.”
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What are the steps of recovery?

There are six stages that addicts must undergo for long-term recovery:

Transition – The period of time needed for the addict to realize that safe use of alcohol or other drugs for them is not possible.

Stabilization – The period of time in which the addict experiences physical withdrawal and other medical problems and learns how to separate from the people, places and things that promote drug abuse.

Early recovery – When an individual faces the need to establish a chemical-free lifestyle and builds relationships that support long-term recovery.

Middle recovery – The time for developing a balanced lifestyle where repairing past damage is critical.

Late recovery – The period of time in which the individual identifies and changes mistaken beliefs about oneself, others, and the world that causes or promotes irrational thinking.

Maintenance – The lifelong process of continued growth, development and management of routine life problems.
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Do addicts ever fully recover?

Addicts should realize that their life can never be the way it was before their addiction. This does not mean that a recovering addict cannot live a healthy and fulfilling life. Rather, addicts should be aware that recovery is a process that always will need to be maintained.
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Is abstinence/sobriety the same as recovery?

No. Sobriety or abstinence is simply refraining from the ingestion of alcohol or other drugs. Recovery is the process by which the ingestion of alcohol or other drugs is recognized as problematic and avoided.

Posted July, 31 2009

From:

http://www.dol.gov/asp/programs/drugs/workingpartners/sab/recovery.asp#q1

Researchers in Chicago apply an old medical maxim: “Chronic diseases require chronic cures.”

Supplementing regular recovery checkups with motivational interviewing and active linking to treatment can get relapsing patients back into treatment sooner and help them stay longer, report NIDA-funded researchers. In the 2 years following treatment, patients who received the additional interventions were three times as likely to reenter treatment as others who received assessments only.

Lead investigator Dr. Christy Scott and coinvestigator Dr. Michael Dennis developed the effective intervention, which they call the Recovery Management Checkup (RMC) system, to expedite the recovery of people who had attended treatment and were now living in the community and experiencing substance abuse problems. They say the findings suggest that their approach to treating substance abuse as a chronic condition may help patients shake off the shame of relapse. “By the time patients had participated in checkups for 2 years, many who were initially reluctant to reenter treatment would call a peer to link them with help after a slip,” says Dr. Scott, of Lighthouse Institute in Chicago, a Division of Chestnut Health Systems, Inc.
INTERVENTION MATCHES RELAPSE PATTERNS

In developing the RMC system, the researchers built on previous studies in which they had identified patterns of chronic substance abuse, relapse, and recovery. They found that, during the first 3 years after treatment, people frequently transitioned between recovery, substance abuse, and treatment—a cyclic pattern suggesting that periodic checkups, with intervention when necessary, might help shorten relapse episodes. They also researched approaches used to manage other chronic health conditions and found that monitoring for relapse and reducing the time from relapse to treatment reentry improved long-term outcomes.

To implement the RMC system, Drs. Scott and Dennis hired and trained a cadre of research assistants and linkage managers, many of whom were local recovering individuals. Chestnut staff and clinical colleagues at Haymarket Center, the largest addiction treatment provider in Illinois, interviewed 448 men and women who had met the standard criteria for a substance abuse diagnosis at some time in their lives, had abused alcohol or other drugs in the past 90 days, were not in protective custody, and intended to live in Chicago for the next year. Cocaine, alcohol, opiates, and marijuana were the most commonly abused drugs. Immediately following the interview, patients received a referral to Haymarket Center for treatment—60 percent as residents and 40 percent as outpatients—for 27 days, on average; 11 percent remained in treatment for 90 days or more. Upon leaving treatment, each patient scheduled eight quarterly followup appointments. Before the first checkup, researchers randomly assigned the patients to either the RMC intervention or an assessment-only control group.

At each checkup appointment, patients met with a research assistant. The assistant administered a 45-minute version of the Global Appraisal of Individual Needs assessment and ascertained information about the patient’s living situation and substance involvement. If the patient had not abused any substance during the past 90 days, the assistant encouraged continued abstinence and scheduled the next appointment. Patients who reported slips were merely advised to reenter therapy if they were in the control group, but met with a linkage manager if they were in the intervention group and living in the community.

The linkage manager conducted motivational interviews, usually lasting less than 30 minutes, in which he or she provided feedback on patients’ substance abuse and related problems, discussed ways to work through barriers to treatment reentry, and considered motivations to return to therapy. If a patient was willing to reenter treatment (even with low motivation), the linkage manager scheduled an appointment, telephoned with a reminder, and arranged transportation. The linkage manager provided assistance for 2 weeks, but afterward, responsibility for continuing therapy fell to the patient. Between RMC appointments, the patient received cards and calls from the research office; these served as a reminder of the next visit and carried a message of support from the research team.
CHECKUPS BOOST CHECK-INS

The researchers were able to interview patients at both the beginning and end of a quarter in 87.5 percent of cases. They categorized each patient’s current status as in the community abusing substances, in treatment, in recovery (no substance abuse, problems, or treatment while living in the community), or incarcerated. Between the beginning and end of each quarter, about one-third of the patients, on average, transitioned from one status to another. Most (82 percent) transitioned at least once during the study, with 62 percent moving between points several times (see chart).

Among patients who relapsed, 67 percent of RMC patients reentered treatment within 90 days after the checkup, compared with 51 percent of assessment-only patients. RMC patients returned to treatment sooner (27 versus 45 days) and stayed in treatment longer (7.75 versus 4.68 days), on average, than the control group. Length of treatment predicted transition to recovery at the next quarterly assessment—for every 10.5 days in treatment, a patient was 1.2 times more likely to be abstinent at the next quarterly checkup.

“The checkups help a patient evaluate his or her behavior and recovery-related issues—much as a person with diabetes would report on blood sugar levels and diet and exercise patterns,” says Dr. Thomas Hilton of NIDA’s Division of Epidemiology, Services and Prevention Research. “By employing individuals in recovery as linkage managers, the program also offered an opportunity for the patient to return to treatment or at least receive support from someone who has been there.”

Drs. Scott and Dennis plan to tailor the checkups for specific populations—for example, women involved in the criminal justice system. Treatment providers who want to implement the checkups can contact Dr. Scott (cscott@chestnut.org).

SOURCE

Scott, C.K.; Dennis, M.L.; and Foss, M.A. Utilizing recovery management checkups to shorten the cycle of relapse, treatment reentry, and recovery. Drug and Alcohol Dependence 78(3):325-338, 2005. [Abstract]

Posted July 30, 2009

By Lori Whitten, NIDA NOTES Staff Writer

From:

http://www.nida.nih.gov/NIDA_notes/NNvol20N6/Checkup.html

Many crimes are rooted in alcohol and drug addictions. Yet, too often, nonviolent offenders are simply sent to jail and not treated for the addiction problems that led them there.

When we release individuals with untreated addictions back into communities, they usually return to their friends, their habits, and their crimes.

More than half of those in the criminal justice system who complete treatment programs and participate in aftercare do not commit new crimes. Most prisoners who serve mandatory sentences, but get no treatment, commit new crimes and start using drugs or alcohol soon after release.

Drug courts are designed to help people with addictions who are facing criminal charges get through treatment and recover from their addiction. Their basic premise is to leverage the authority of the criminal-justice system to keep defendants in treatment, recognizing that the recovery process may well include lapses and relapses, but the longer a person stays in treatment, the greater chance he/she has for sustained recovery.

While the participant is enrolled in the drug court, final disposition of the criminal charges is suspended and — depending upon the participant’s ultimate success or failure — may be dismissed or otherwise changed.

It is widely recognized that drug courts result in varying degrees of reduced recidivism and cost savings for the criminal-justice system, and are most effective with high-risk, defendants with a long history of addictions.

In addition, drug courts produce many other societal benefits, including increased coordination and delivery of public health and mental health services, vocational training and job placement which increase the likelihood of sustained recovery.

Posted July, 29, 2009

From:

http://www.jointogether.org/keyissues/incarceration/treatment-vs-incarceration-readmore.html

Vol. 22, No. 2 (December 2008)

Low-risk offenders do equally well with and without regularly scheduled court appearances.

Adjusting the frequency of mandatory drug court monitoring sessions according to offenders’ risk of lapsing into criminal activity, including drug abuse, can enhance program success rates while conserving resources, according to a recent NIDA-supported study. Researchers found that high-risk drug offenders—those with antisocial personality disorder or prior histories of drug abuse treatment—achieved better outcomes when ordered to attend a judicial status hearing every 2 weeks, rather than at the 4- to 6-week intervals that drug courts typically impose. In contrast, lower risk offenders’ treatment success was not compromised when courts required them to appear only if they committed serious or repeated infractions of program rules.

“Our research represents a first step in tailoring adaptive supervision interventions to drug-abusing offenders,” says Dr. Douglas Marlowe of the Treatment Research Institute and the University of Pennsylvania, Philadelphia. Dr. Marlowe, Dr. David Festinger, and colleagues conducted the study as part of a broader effort to improve the efficacy and cost-effectiveness of drug court interventions by identifying which components of the model work best for various groups of drug offenders.
CUSTOM TAILORING COURT SUPERVISION

Drug courts are intensive, community-based programs that substitute judicially supervised treatment and case management for prosecution or incarceration. Defendants who complete the drug court program and remain arrest-free for 6 months after graduation have their charges dropped and their arrest records expunged. The judicial status hearing, during which a judge rewards achievements and punishes infractions with sanctions that progressively increase in severity, is among the costliest components of drug court programs.

Drs. Marlowe and Festinger designed their study to answer two questions: Would high-risk drug offenders benefit from hearings held more frequently than usual, and would low-risk drug offenders still experience treatment gains if their hearings were held less often than the norm? The researchers had reason to predict the answers would be “yes” to both questions because of observations they had made in a previous study. That study’s design and small participant population, however, had not allowed definitive findings on these issues.

Participants in the new study were recruited from a misdemeanor drug court in Wilmington, Delaware. Among the drugs that they reported abusing at the time of their assignment to drug court, cannabis was the most common, followed by alcohol, stimulants or cocaine, opiates, sedatives, and hallucinogens. Each participant was assigned to a clinical case manager who coordinated treatment referrals, submitted monthly reports to the judge, and appeared at the participant’s judicial status hearings.

Ninety-two of the 279 participants were classified as high-risk because they had an antisocial personality disorder or had relapsed after previous treatment for drug abuse. Within the high-risk group, 42 were assigned to report to drug court biweekly, and 50 reported every 4 to 6 weeks. In the low-risk group, 92 were put on the 4- to 6-week schedule, and 95 were told to appear in court only after serious rule infringements—most commonly failure to attend counseling appointments or provide drug-free urine specimens.

Within a year, 75 percent of the high-risk participants who attended hearings every 2 weeks graduated from the program, compared with 56 percent of high-risk participants assigned to follow the standard schedule. The former group also provided more drug-free urine samples and reported less alcohol intoxication (see table), as well as less criminal activity.

Among the low-risk participants, outcomes were similar regardless of how often hearings took place. For example, program graduation rates were 75 percent among the offenders who appeared in drug court every 4 to 6 weeks and 72 percent among those who appeared in court only when a problem arose, averaging less than two hearings during the study year. “Reducing the number of court hearings for these individuals could permit a program to conserve costly resources without sacrificing client outcomes or public safety,” Dr. Marlowe says.

DRUG COURT FREQUENCY CAN AFFECT TREATMENT OUTCOME Participants who were considered high-risk provided more drug-free urine samples when they were required to appear in drug court every 2 weeks (gray-green) rather than according to the standard schedule of every 4 to 6 weeks (gold). In contrast, participants who were at lower risk of relapse did comparably well on the standard schedule (blue) and when court appearances were scheduled only in response to treatment-rule infractions (red).
DRUG COURT FREQUENCY CAN AFFECT TREATMENT OUTCOME – line graph. Week in Drug Court in relation to the percentage of drug-free urine samples. See previous text for additional information. Source: Marlowe, D.B., et al. Matching judicial supervision to clients’ risk status in drug court. Crime and Delinquency 52, 52-76, 2006.
ROOM FOR IMPROVEMENT

“Adjusting the frequency of court hearings to participants’ risk status will make a difference, but there still will be considerable room for improvement in drug court outcomes,” Dr. Marlowe notes. For high-risk participants who continue to have drug or alcohol problems, the program needs further tailoring, he explains. Those who are not compliant with the program—for example, those who fail to attend counseling sessions or to deliver urine specimens—might respond to more frequent judicial supervision or to sanctions such as home curfews. In contrast, increasing the scope of treatment services might be more effective with high-risk participants who are compliant with program rules but fail to achieve abstinence because of the severity of their drug addiction or a related difficulty, such as a co-occurring mental disorder, family problems, unemployment, or homelessness. Dr. Marlowe notes that even low-risk drug offenders need more effective interventions.

“Dr. Marlowe is helping us fill our knowledge gap about drug courts by identifying the elements that make them effective,” says Dr. Redonna K. Chandler, chief of NIDA’s Services Research Branch. “We may eventually be able to match criminal justice supervision and treatment services to the needs of individual offenders, making drug courts both more effective and more costeffective.” Dr. Marlowe says, “We hope that drug court programs eventually become flexible enough to allow participants doing poorly to be switched to a more intensive track and allow those doing well in an intensive program to move to a lower supervision regimen.”

SOURCE

Marlowe, D.B., et al. Adapting judicial supervision to the risk level of drug offenders: Discharge and 6-month outcomes from a prospective matching study. Drug and Alcohol Dependence 88(Suppl. 2):S4-13, 2007. [Abstract]

Drug Courts Add Value

Studies have shown that drug courts significantly increase the time drug abusers stay in treatment. An average of 60 percent of drug court clients complete at least 12 months of treatment, whereas only 10 percent of probationers and parolees typically remain for a year in community-based drug treatment programs, says Dr. Douglas Marlowe of the University of Pennsylvania, summarizing several research reports. A 1998 review of 13 drug court studies found that drug court clients abuse substances less frequently than comparable probationers (10 percent of urine tests were positive, compared with 31 percent). What’s more, drug courts reduce re-arrest rates by 8 to 24 percent, according to five meta-analyses in 2005 and 2006. Although drug courts tend to be more expensive than other programs, the reduction in recidivism decreases later judicial costs and financial loss to crime victims, according to a U.S. Government Accountability Office report published in 2005.* It cited net predicted benefits of $1,000 to $15,000 per participant.

*Adult Drug Court: Evidence Indicates Recidivism Reduction and Mixed Results for Other Outcomes, GAO-05-219, February 2005.

By:  NIDA Notes Staff

Posted July, 28 2009

From:

http://www.nida.nih.gov/NIDA_notes/NNVol22N2/HighRisk.html#insert

By Bob Curley

Addiction treatment is included in the minimum benefits packages in all three major national healthcare reform bills now being considered by Congress, and each also includes equal coverage of addiction-related services as outlined in the 2008 Wellstone parity bill.

Carol McDaid of Capital Decisions, who lobbies on behalf of addiction treatment and prevention organizations,said that of the five “big buckets” that advocates for addiction services need to fill in the healthcare reform debate, at least these two are being treated favorably by lawmakers, while work still needs to be done on three others — prevention, workforce development, and electronic health records.

“We’re thrilled [addiction treatment is] in at this point,” said Victor Capoccia, Ph.D., director of the Closing the Addiction Treatment Gap (CATG) program, which this week issued a white paper stating that covering addiction treatment services under healthcare reform could make a major contribution to cutting health costs.

Compared to the last big health reform battle on Capital Hill — Hillary Clinton’s ill-fated stab at universal coverage in 1993-94 — “we’re in much better shape as a field in terms of advocacy,” said McDaid.

That’s due in part to the fact that the field waged a recent and successful battle for inclusion in and passage of the parity law, so the arguments in favor of addiction treatment coverage are still fresh in policymakers’ minds, noted McDaid.

Also, federal agencies like the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Office of National Drug Control Policy have been far more engaged in collaborating with the field under the Obama administration, and cooperation between the addiction and mental-health communities has matured and coalesced around the Coalition for Whole Health, said McDaid.

For example, SAMHSA recently issued a consensus statement calling for addiction and mental health services to be included in healthcare reform and outlining a series of core principles for reform, while the Coalition for Whole Health has drafted legislative language reflecting the field’s priorities.

CATG, funded by the Open Society Institute, helped organize a July 17 briefing for Washington, D.C., policymakers on the case for addiction treatment in health reform. The hearing, which was attended by more than 230 people, will be followed by a series of regional policy panels during the Congressional summer recess, according to Capoccia. The group also sponsored a survey released in June showing that a solid majority of American support inclusion of addiction treatment in national healthcare reform, and plans a more detailed followup survey later this summer.

Progress on Prevention

Addiction-field advocates have made some progress towards ensuring that alcohol and other drug prevention services are included in the preventive-health provisions of the healthcare reform legislation. The bills will also cover screening and brief intervention for problem drinking as a covered preventive service. “This is enormously important, because research has shown that widespread screening can lead to significant reductions in alcohol related medical expenses,” said David Rosenbloom, president and CEO of the National Center on Addiction and Substance Abuse (CASA) at Columbia University.

However, “There are certainly gaps in how coverage will be included” for prevention services, cautioned Capoccia.

Advocates also are working to ensure that addiction-treatment professionals can share in the workforce-development programs envisioned under the various bills, such as forgiveness for educational loans and increased slots for medical residents. “It could become a real issue if we get parity and have a big increase in patients with no providers to serve them,” pointed out McDaid.

Finally, field leaders are pressing lawmakers to ensure that addiction-treatment providers can tap into assistance to develop and enhance electronic health records to improve coordination and efficiency, while at the same time recognizing the special confidentiality issues inherent in addiction treatment, McDaid said.

Currently, the addiction field “comes out better in the House Tri-Committee bill,” said McDaid, although she stressed that the measures are “good across the board.” None of the bills deal with the specifics of healthcare benefits, which would be spelled out after passage by special committees established under the reform act.

A ‘Secret Weapon’ to Cut Healthcare Costs

Capoccia goes beyond arguing for simple inclusion, arguing that expanding addiction treatment for the estimated 20 million American who need it could be a “secret weapon” for cutting overall healthcare costs in the U.S. “When you treat people, their use of general medical services and associated costs both decrease,” he said. “Even if you only help one-fifth, 25 percent of them, it begins to translate into lost of money on an annual basis — to say nothing of the fact that people with an illness should get treatment, period.”

CASA’s Rosenbloom urged lawmakers to consider raising the federal tax on alcohol as part of health-reform legislation. “It will raise a lot of the money needed to pay for reform and also lower future medical care costs,” he said. “When the price of alcohol goes up, problematic drinking by young people and the small number of very heavy drinkers goes down.” Rosenbloom said research shows that governments currently spend $7 dealing with the consequences of excessive alcohol use for every dollar they collect in alcohol taxes.

McDaid — who would like to convince lawmakers to get the Congressional Budget Office to score addiction treatment services and conduct a cost-benefit analysis of inclusion in health reform — said she’s not surprised that the public and members of Congress are reacting sharply to the cost of healthcare reform now that specifics are emerging. She expects that the debate will stretch out much further than the summer.

“I still believe we will get something done, though I think Congress may be in until Christmas Eve,” she said. “The question is how significant will it be — will it be incremental or a whole-system reform?”

McDaid is less concerned about Congress backtracking on providing coverage for addiction treatment services. “I think many of the victories we have had will be sustained” in whatever reform bill passes, she said.

What Comes After Reform?

For the addiction field, the hard work will hardly be starting if and when the ink dries on a healthcare reform bill. While lawmakers may be willing to finally deny the myth that addiction treatment is too expensive and accept that it saves money in the long run — and Washington’s recent embrace of drug courts suggests they are — the field still faces tremendous challenges in terms of accountability and lack of integration with the mainstream healthcare system.

Capoccia said that there is good outcome data to support certain types of treatment, such as medication-assisted programs and those using motivational enhancement and interviewing techniques. Standards developed by the National Quality Forum have been adopted by some states to guide purchasing decisions.

But many programs still lack credible outcome data, and Capoccia predicted that programs that lack accountability and quality standards will be “winnowed out” within five years of healthcare reform passing. “Accountability is written all over healthcare reform,” he said.

Capoccia added that healthcare reform is likely to force addiction treatment providers to become more sophisticated and comprehensive in the services they offer to the patients they “own” — namely, those with severe or persistent addiction or mental-health problems. “If we own them, we’ll have to provide or link to general medical care, too,” he said.

Currently, however, “Our field is woefully unprepared to make the changes necessary to operate in a healthcare-reform environment,” said Capoccia.

Posted July 27, 2009

By: Bob Curley

From:

http://www.jointogether.org/news/features/2009/positive-prognosis-for.html

More than 25 states as well as Washington, D.C., are exploring alternative-sentencing methods and revamping probation and parole programs to cut the rising cost of keeping inmates in prison, the Washington Post reported July 13.

Governors and legislatures are particularly investing in drug courts, which offer low-level drug offenders treatment and weekly meetings with a judge as a way of keeping them from serving prison time.  States are also turning to the 500 courts nationwide designated for people arrested for driving under the influence, so that offenders will be sent to treatment programs and undergo random tests instead of being sent to jail.

Probation time in some states is also being reduced, as is the number of people sentenced to prison for minor violations such as failing to appear for scheduled court appointments.

“The economy is bringing a lot of states to the table,” said Adam Gelb, who directs the Pew Center on the States Public Safety Performance Project. “The research has pointed to a path for them to [provide] more public safety at less cost.”

The average cost to keep an inmate in prison is $79 per day, whereas the daily cost to monitor that person through probation or parole is $3.50, according to the Pew Center.

In an effort to reduce its prison spending, New York has eased mandatory-minimum drug laws enacted during the Rockefeller era, and Virginia is currently seeking sentencing alternatives for its nonviolent offenders.  President Barack Obama has requested more than $200 million from Congress for prisoner-reentry programs.

Posted July 24, 2009

From:

http://www.jointogether.org/news/headlines/inthenews/2009/states-exploring-drug-courts.html?log-event=sp2f-view-item&nid=53970334

1.      Why do people involved in the criminal justice system continue abusing drugs?

The answer to this perplexing question spans basic neurobiological, psychological, social, and environmental factors.

The repeated use of addictive drugs eventually changes how the brain functions. Resulting brain changes, which accompany the transition from voluntary to compulsive drug use, affect the brain’s natural inhibition and reward centers, causing the addict to use drugs in spite of the adverse health, social, and legal consequences (Volkow, Fowler, Wang, et al., 1993; Volkow, Hitzemann, Wang, et al., 1992; Volkow and Li, 2004). Craving for drugs may be triggered by contact with the people, places, and things associated with prior drug use, as well as by stress. Forced abstinence without treatment does not cure addiction. Abstinent individuals must still learn how to avoid relapse, including those who have been incarcerated and may have been abstinent for a long period of time.
Addictive Drugs Can Cause Long-Lasting Changes in the Brain
Addictive Drugs Can Cause Long-Lasting Changes in the Brain
PET scans showing glucose metabolism in healthy brain and cocaine-addicted brains. Even after 100 days of abstinence, glucose metabolism has not returned to normal levels.

Potential risk factors for released offenders include pressures from peers and even family members to return to drug use and a criminal lifestyle. Tensions of daily life—violent associates, few opportunities for legitimate employment, lack of safe housing, even the need to comply with correctional supervision conditions—can also create stressful situations that can precipitate a relapse to drug use.

Research on how the brain is affected by drug abuse promises to help us learn much more about the mechanics of drug-induced brain changes and their relationship to addiction. Research also reveals that with effective drug abuse treatment, individuals can overcome persistent drug effects and lead healthy, productive lives.

2.     Why should drug abuse treatment be provided to offenders?

The case for treating drug abusing offenders is compelling. Drug abuse treatment improves outcomes for drug abusing offenders and has beneficial effects for public health and safety. Effective treatment decreases future drug use and drug-related criminal behavior, can improve the individual’s relationships with his or her family, and may improve prospects for employment.

Outcomes for substance abusing individuals can be improved when criminal justice personnel work in tandem with treatment providers on drug abuse treatment needs and supervision requirements. Treatment needs that can be assessed after arrest include substance abuse severity, mental health problems, and physical health. Defense attorneys, prosecutors, and judges need to work together during the prosecution and sentencing phases of the criminal justice process to determine suitable treatment programs that meet the offender’s needs. Through drug courts, diversion programs, pretrial release programs conditional on treatment, and conditional probation with sanctions, the offender can participate in community-based drug abuse treatment while under criminal justice supervision. In some instances, the judge may recommend that the offender participate in treatment while serving jail or prison time or require it as part of continuing correctional supervision postrelease.

3.     How effective is drug abuse treatment for criminal justice-involved individuals?

Treatment is an effective intervention for drug abusers, including those who are involved with the criminal justice system. However, the effectiveness of drug treatment depends on both the individual and the program, and on whether interventions and treatment services are available and appropriate for the individual’s needs. To amend attitudes, beliefs, and behaviors that support drug use, the drug abuser must engage in a therapeutic change process. Longitudinal outcome studies find that those who participate in community-based drug abuse treatment programs commit fewer crimes than those who do not participate.

4.     Are all drug abusers in the criminal justice system good candidates for treatment?

A history of drug use does not in itself indicate the need for drug abuse treatment. Offenders who meet drug dependence criteria should be given higher priority for treatment than those who do not. Less intensive interventions, such as drug abuse education or self-help participation, may be appropriate for those not meeting criteria for drug dependence. Services such as family-based interventions for juveniles, psychiatric treatment, or cognitive-behavioral “criminal thinking” interventions may be a higher priority for some offenders, and individuals with mental health problems may require specialized services (see FAQ Nos. 6 and 12).
Outcomes can be improved when criminal justice personnel work in tandem with treatment providers.

Low motivation to participate in treatment or to end drug abuse should not preclude access to treatment if other criteria are met. Motivational enhancement interventions may be useful in these cases. Examples include motivational interviewing and contingency management techniques, which often provide tangible rewards in exchange for meeting program goals. Legal pressure that encourages abstinence and treatment participation may also help these individuals by improving retention and catalyzing longer treatment stays.

Drug abuse treatment is also effective for offenders who have a history of serious and violent crime, particularly if they receive intensive, targeted services. The economic benefits in avoided crime and costs to crime victims (e.g., medical costs, lost earnings, and loss in quality of life) may be substantial for these high-risk offenders. Treating them requires a high degree of coordination between drug abuse treatment providers and criminal justice personnel to ensure that treatment and criminogenic needs are appropriately addressed.

5.     Is legally mandated treatment effective?

Legal pressure can increase treatment attendance and improve retention.

Often the criminal justice system can apply legal pressure to encourage offenders to participate in drug abuse treatment; or treatment can be mandated, for example, through a drug court or as a condition of pretrial release, probation, or parole. A large percentage of those admitted to drug abuse treatment cite legal pressure as an important reason for seeking treatment. Most studies suggest that outcomes for those who are legally pressured to enter treatment are as good as or better than outcomes for those who entered treatment without legal pressure. Those under legal pressure also tend to have higher attendance rates and to remain in treatment for longer periods, which can also have a positive impact on treatment outcomes.

6.     Are relapse risk factors different in offender populations? How should drug abuse treatment deal with these risk factors?

Often, drug abusing offenders have problems in other areas. Examples include family difficulties, limited social skills, educational and employment problems, mental health disorders, infectious diseases, and other medical problems. Treatment should take these problems into account, because they can increase the risk of drug relapse and criminal recidivism if left unaddressed.

Stress is often a contributing factor to relapse, and offenders who are re-entering society face many challenges and stressors, including reuniting with family members, securing housing, and complying with criminal justice supervision requirements. Even the many daily decisions that most people face can be stressful for those recently released from a highly controlled prison environment.
Returning to environments associated with drug use may trigger cravings and cause a relapse.

Other threats to recovery include a loss of support from family or friends, which incarcerated people may experience. Drug abusers returning to the community may also encounter family, friends, or associates still involved in drugs or crime and be enticed to resume a criminal and drug using lifestyle. Returning to environments or activities associated with prior drug use may trigger strong cravings and cause a relapse. A coordinated approach by treatment and criminal justice staff provides the best way to detect and intervene with these and other threats to recovery. In any case, treatment is needed to provide the skills necessary to avoid or cope with situations that could lead to relapse.

Treatment staff should identify the offender’s unique relapse risk factors and periodically re-assess and modify the treatment plan as needed. Generally, continuing or re-emerging drug use during treatment requires a clinical response—either increasing the “dosage” or level of treatment, or changing the treatment intervention.

7.     What treatment and other health services should be provided to drug abusers involved with the criminal justice system?

One of the goals of treatment planning is to match evidence-based interventions to individual needs at each stage of drug treatment. Over time, various combinations of treatment services may be required. Evidence-based interventions include cognitive-behavioral therapy to help participants learn positive social and coping skills, contingency management approaches to reinforce positive behavioral change, and motivational enhancement to increase treatment engagement and retention. In those addicted to opioid drugs, agonist/partial agonist medications can also help normalize brain function, and antagonist medications can facilitate abstinence. For juvenile offenders, treatments that involve the family and other aspects of the drug abuser’s environment have established efficacy.

Drug abuse treatment plans for incarcerated offenders can anticipate their eventual re-entry into the community by incorporating relevant transition plans and services. Drug abusers often have mental and physical health, family counseling, parenting, educational, and vocational needs, so medical, psychological, and social services are often crucial components of successful treatment. Case management approaches can be used to provide assistance in obtaining drug abuse treatment and community services.

Posted July, 23, 2009

From:  NIDA Information for Medical and Health Professionals

http://www.drugabuse.gov/PODAT_CJ/faqs/faqs1.html#1

By Lori Whitten, NIDA NOTES Staff Writer

Telephone-based continuing care, in which an addiction counselor supports patient recovery with 15-minute calls once a week, can be as good as or better than face-to-face care at helping most patients maintain abstinence after intensive outpatient treatment (IOP). In a recent NIDA-funded study, the benefits of a telephone support protocol were evident nearly 2 years after the last call for all but the 20 percent of patients with severe addiction problems that did not resolve during IOP.

“Telephone-based continuing care does not require transportation or interfere much with work or childcare responsibilities, and this flexibility may help patients stay engaged in recovery and maintain the gains achieved during initial inpatient or outpatient treatment,” says Dr. James McKay, lead researcher of the study.

Dr. McKay and colleagues at the University of Pennsylvania, the Treatment Research Institute in Philadelphia, and Brandeis University worked with two Philadelphia-area outpatient addiction programs. Patients seeking treatment in these programs received about 9 hours of outpatient group therapy each week for 1 month, on average. The therapy concentrated on overcoming denial of substance abuse, learning about the addiction process and cues to relapse, and beginning self-help participation. Dr. McKay and colleagues recruited patients who “graduated” from therapy—that is, continued in the IOP and achieved abstinence in the last week—to receive 12 weeks of continuing care and followup for 2 years.

The patients, 359 men and women aged 18 to 65, were typical, in terms of demographics and problem severity, of individuals seeking treatment at publicly funded outpatient addiction programs. Half met the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for co-occurring cocaine and alcohol dependence, 87 were dependent on cocaine only, and 91 were alcoholic. Thirty percent had met the criteria for a diagnosis of major depression at some time in their lives. When they began treatment, they reported 8 years of cocaine and 18 years of alcohol abuse, on average, and multiple attempts to quit.

Telephone Counseling Helps Outpatient Treatment
Graduates Stay Abstinent
Graph – Months after graduation     Two years after graduating from intensive outpatient treatment, more patients who participated in telephone-based continuing care (TELE) had maintained abstinence during the previous 3 months than those receiving standard group counseling (STND). The percentage of abstinent patients did not differ between TELE and relapse prevention (RP) continuing care.
Graph – Number of High-Risk Characteristics     Throughout the study, patients with four or more characteristics reflecting severe addiction were better able to maintain abstinence if they participated in STND compared with TELE.
Graph – Months after graduation     The percentage of cocaine-positive urine samples did not increase as quickly during the followup for TELE patients as it did for those who participated in RP, with a similar trend for TELE compared with STND.

All patients participated in 12 weeks of continuing care after completing a month of intensive outpatient treatment, and reported outcomes every 3 months during the 2-year followup.
Regular Contact With a Therapist Is Crucial

The investigators randomly assigned each patient to one of three continuing care therapies: a face-to-face therapy, either standard group (STND) or relapse prevention (RP); or telephone-based (TELE) counseling. In STND care, the most common approach to continuing care for addiction, 122 patients attended twice-weekly counseling sessions that emphasized overcoming denial and engaging in mutual and self-help activities. In RP therapy, 135 patients attended an individual session of cognitive-behavioral therapy and then group sessions once a week. In this approach, patients identify situations that prompt substance abuse and work to improve coping responses using structured activities and homework exercises.

In TELE care, 102 patients met with counselors in person the week before beginning the telephone phase to discuss the therapy and receive a workbook with exercises that structured subsequent calls. At a scheduled time each week, they telephoned counselors and talked for 15 to 20 minutes about progress during the previous week, any episodes of substance abuse, participation in self-help and other pro-recovery activities, plans for achieving the next week’s goals, and any concerns. Counselors contacted patients who did not call and discussed in a supportive way their reasons for not doing so. To ease the transition from outpatient to continuing care, therapists offered the TELE patients group counseling once a week for a month. Patients struggling with relapse at that point could continue with group sessions; more than a third (35 percent) exercised this option.

The researchers followed up with patients every 3 months throughout the study and contacted 86 percent 2 years after graduation from IOP. At this point, about two-thirds of TELE patients reported abstinence during the previous 3 months, compared with about half of those who had participated in STND. An analysis of urine samples from the cocaine-addicted patients showed an overall increase in the percentage of cocaine-positive samples during the followup period, but the increase was more rapid among RP participants than TELE participants. The TELE group had higher abstinence rates than STND throughout followup. Patients who participated in TELE maintained the gains of IOP even though they received about half as much therapeutic contact (428 minutes) as those receiving STND or RP (845 and 861 minutes, respectively).

“Continuing care benefits people in recovery in several ways, but regular contact with a therapist is crucial for patients with a chronic condition, and especially helps patients who have relapsed get back into treatment,” says Dr. Dorynne Czechowicz of NIDA’s Division of Clinical Neurosciences, Development and Behavioral Treatments. Although larger studies with more diverse patients are needed, Dr. McKay and his colleagues laid important groundwork, she says.
Face-to-Face Care for Severe Problems

Some patients need more contact with a counselor than telephone-based continuing care affords to maintain recovery. To identify these patients, Dr. McKay and his colleagues examined the link between outcomes and seven patient characteristics: co-occurring addiction to alcohol and cocaine at the beginning of IOP; any alcohol use, any abuse of cocaine, minimal attendance at self-help meetings, below-average social support during IOP; and a lack of commitment to complete abstinence, and low self-efficacy for recovery at the end of IOP.

Patients who demonstrated three or fewer of the characteristics—about 80 percent of the study population—did at least as well with TELE continuing care as with the other two approaches. But the remaining patients, those who met the criteria for co-occurring addiction at the beginning of treatment and did not achieve the main goals of IOP—abstinence from cocaine and alcohol during treatment, commitment to abstinence, and participation in self-help programs—were at high risk for relapse and showed better outcomes with STND continuing care, relative to TELE, during most of the followup. The findings suggest that TELE may be inappropriate for patients with more severe addiction problems until they demonstrate stable abstinence from drugs and alcohol, says Dr. McKay.
Flexible Continuing Care

“Some practitioners are developing flexible arrangements to engage and retain more patients in continuing care,” says Dr. McKay. Flexibility in the practical sense—the ability to call one’s counselor from any location—extends participation in continuing care, not only to busy people, but also to those living in rural areas or who have lost driver’s licenses.

Telephone-based care is one way that a treatment intervention can respond to each patient’s progress during recovery; it gives counselors the flexibility to intensify care if the patient is struggling to maintain abstinence. “Clinicians managing other chronic disorders—for example, hypertension and cancer—are using progress during initial treatment to determine subsequent care. It’s not a new therapeutic approach, but it is novel to addiction treatment,” Dr. McKay says.

Sources

* McKay, J.R.; Lynch, K.G.; Shepard, D.S.; and Pettinati, H.M. The effectiveness of telephone-based continuing care for alcohol and cocaine dependence. Archives of General Psychiatry 62(2):199-207, 2005. [Abstract]
* McKay, J.R., et al. Do patient characteristics and initial progress in treatment moderate the effectiveness of telephone-based continuing care for substance use disorders? Addiction 100(2):216-226, 2005. [Abstract]

By Lori Whitten

Posted July 21, 2009

From

http://www.nida.nih.gov/NIDA_notes/NNvol20N3/Telephone.html

Volume 20, Number 3 (October 2005)

July 17, 2009

Local news media in Ciudad Juarez, Mexico, estimate that more and more of the nearly 700 people killed so far this year, were people with addictions seeking treatment at local centers, the Washington Post reported June 14.

Some local officials and addiction counselors said that they believed patients in the treatment centers may owe local drug dealers money, work for competing gangs, or have stolen drugs — or that the high rate of unsolved murders in the border town may have contributed.

“Many people sell drugs during the day and sleep at the centers during the night. That’s the problem. Their troubles come home with them,” said Victor Silerio, who runs a treatment center that — unlike most in the vicinity — restricts patients’ access to leave and re-enter the facility.

At least seven treatment centers have closed since receiving threats from local drug gangs, said Silerio.

Local officials said that when about 10,000 soldiers policed Ciudad Juarez for a few months earlier in the year, the number of murders per day decreased.

Posted July 21, 2009

From

http://www.jointogether.org/news/headlines/inthenews/2009/drugs-murder-inundate-border.html

While each family member is responsible for his or her own recovery and no one can recover for another, the symptoms of addiction and co-addiction each impact upon the relapse potential of the other. Even if the alcoholic/addict is no longer drinking or using and no longer experiencing the alcohol/drug-related symptoms of the disease, the post acute withdrawal symptoms affect and are affected by co-addiction. Both the symptoms of post acute withdrawal and the symptoms of co-addiction are stress sensitive. Stress intensifies the symptoms and the symptoms intensify stress. As a result, the recovering addict and the co-addict can become a stress-generating team that unknowingly and unconsciously complicates each other’s recovery and create a high risk of relapse.
What can family members do to reduce the risk of their own relapse and the risk of relapse in the recovering addict? They can become informed about the addictive disease, recovery, and the symptoms that accompany recovery. They must recognize that the symptoms of post acute withdrawal are sobriety-based symptoms of addiction rather than character defects, emotional disturbances, or mental illness. At the same time they must accept and recognize the symptoms of co-addiction and become involved in Al-Anon and/or personal therapy as they develop plans for their own recovery.
Clinical experience with relapse prevention planning in a variety of treatment programs has indicated that the family can be a powerful ally in preventing relapse in the addict. In 1980, relapse prevention planning was modified to include the involvement of significant others including family members. This significantly increased effectiveness. With further clinical experience, however, other problems became apparent. Many family members refused to participate in relapse prevention planning. Other family members participated in a manner that was counterproductive.

In 1983 relapse prevention planning was expanded to include relapse prevention in both the addicted person and the co-addict. The newly designed relapse prevention planning protocol utilizes the family’s motivation to get the addict sober. As family members become involved in relapse prevention planning, a strong focus is placed upon co-addiction and its role in family relapse. Family members are helped to recognize their own co-addiction and become actively involved in their own treatment. Addiction is presented as a family disease that affects all family members requiring them to get treatment.

All members of an addicted family are prone to return to self-defeating behaviors that can cause them to become out of control. An acute relapse episode can occur with an addict or a co-addict family member. Like addicts who develop serious problems even though they never use alcohol or drugs, the co-addict often becomes dysfunctional even though the addict is sober and working an active recovery program.

It is important to protect the family from the stress that may be generated by the symptoms of post acute withdrawal experiences by the recovering person and to cooperate in plans to protect the recovering person from stress created by symptoms of co-addiction. Remember that none of you became ill overnight. Recovery will, likewise, take place over a long period of time. Develop a plan to prevent personal relapse and support relapse prevention plans for the recovering addict.

Family Relapse Prevention Planning is intended to help prevent acute relapse episodes in the recovering addict, to prevent crisis in the co-addict, to develop a relapse prevention plan for both the addict and co-addict and to develop an early intervention plan to interrupt acute relapse episodes in both the recovering addict and the co-addict. For the addict this involves interrupting problems that are caused both by Post Acute Withdrawal (PAW) Syndrome in the sober addict and by alcohol or drug use in the addict who has returned to drinking or using. For the co-addict this involves interrupting the co-addiction crisis. The family needs to work with a counselor to establish a formal relapse prevention plan that will allow them to support each other’s recovery and to help intervene if the relapse warning symptoms get out of control.

The family relapse prevention planning protocol consists of twelve basic procedures. These are:

1.Stabilization: The first step in relapse prevention planning is to stabilize both the addict and the co-addict. The addict is stabilized through the process of detoxification or treatment of post-acute withdrawal symptoms. The spouse is stabilized by treating the co-addict crisis, through detachment from the addicts crisis, by regaining a reality-based perspective, and the development of some basic personal strengths. This often requires attendance at Al-Anon and professional counseling.

2.Assessment: Prior to developing a relapse prevention plan it is necessary to evaluate the addict, the co-addicts, and the family system.The evaluation should assess the current problems of each family member, their willingness and ability to initiate a personal recovery program, and their willingness to become involved in a program of family recovery.

3.Education about Alcoholism, Co-addiction, and Relapse: Accurate information is the most powerful of all recovery tools. The addict and the family must learn about the disease of addiction, the condition of co-addiction, treatment, and relapse prevention planning. This education is best provided to the family as a unit in multiple family classes. It is helpful if separate group therapy programs accompany the education for each family member. The addict should enter an addict group, the adult co-addict should enter a spouse’s group, and the co-addict children should enter a children’s group. It is in these group treatment sessions that individual recovery of all family members is initiated.

4.Warning Sign Identification: Both the addict and the co-addict need to identify the personal warning signs that indicate that they are becoming dysfunctional. Again, this is best done in a group setting. The addict is better able to identify relapse-warning signs when working with other addicts. Co-addicts are best able to initially identify relapse-warning signs when working with other co-addicts. Relapse warning sign lists for addiction and co-addiction are useful guides for personal warning sign identification.

5.Family Validation of Warning Signs: After each family member has developed a personal list of warning signs and reviewed these in his or her group, a series of family sessions is scheduled. During these sessions all family members present their personal lists of warning signs and ask for feedback. Other family members discuss the warning signs, help assess fi they are specific and observable. New warning signs may be added to the list based upon the feedback of others. Since each family member has a list of warning signs that precede acute relapse episodes there is no identified patient. All participate from a position of equality. They essentially say to each other, “We have all been equally affected, in various ways, by addictive disease.”

6.The Family Relapse Prevention Plan: Family members discuss each of their warning signs, how the family has dealt with those warning signs in the past, and what strategies could be effectively used in the future. Future situations in which the warning signs are likely to be encountered are identified. Strategies for more effective management of the warning signs for each family member are discussed. During this process a great deal of role playing and problem solving occurs. Problems are often identified that are taken back to the separate therapy groups for further work.

7.Inventory Training: All member of the family receive training in how to complete a morning planning inventory and an evening review inventory. These focus heavily upon time structuring, realistic goal setting, and problem solving.

8.Communication Training: The family members must learn to communicate effectively in order for a Relapse Prevention Plan to work. The family is trained in the process of giving and receiving feedback in a constructive and caring manner.

9.Review of the Recovery Program: All family members will report to the family the recovery program that they have established for themselves. This focus here is, “How will you and I know that I am doing well in my recovery?” All are invited to express their recovery needs and point out their progress in treatment.

10.Denial Interruption Plan: Both addiction and co-addiction are diseases of denial. Most of the denial is unconscious. Neither the addict nor the co-addict realizes that they are in denial when it is happening. It is important to take the reality of denial into account early. Each family member should be asked the question, “What are other people in your family supposed to do if they give you feedback about concrete warning signs and you deny it, ignore the feedback, or become angry and upset?” Each family member should recommend specific plans for dealing with their own denial. This open discussion sets the stage for intervention should denial become a problem in the future.

11.The Relapse Early Intervention Plan: Addiction and co-addiction are prone to relapse. Relapse means becoming dysfunctional in recovery. For the recovering addict relapse may ultimately lead to alcohol and drug use, or it may simply mean that the person becomes so depressed, anxious, angry, or upset that he is dysfunctional in sobriety. For the co-addict relapse means the return to a state of co-addict crisis that interferes with normal functioning. Once family members enter an acute relapse episode they are out of control of their thoughts, emotions, judgements, and behavior. They often need the direct help of other family members to interrupt the crisis. Many times they resist this help. They act as if they do not want help even though they desperately need it. The family is instructed in the process of intervention. Intervention is a method of helping people who refuse to be helped. This intervention training has resulted in a radical decrease in the duration and severity of relapse episodes in family members.

12.Follow-up and Reinforcement: Addiction and co-addiction are life-long conditions. The symptoms can go into remission but they never totally disappear. They rest quietly, waiting for a lapse in the recovery program to become active again. It is important that the family maintain an ongoing recovery program including AA/NA, Al-Anon, and periodic relapse prevention checkups with a professional addiction counselor.

This Article is exerpted from “Staying Sober” By: Terence T. Gorski

Posted July16, 2009

From

http://www.recoverycrossroads.com/community/showthread.php?t=3912
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