John F. Kelly1 and William L. White
(1)
Center for Addiction Medicine, Massachusetts General Hospital, 60 Staniford Street Suite 120, Boston, MA 02114, USA
John F. Kelly
Email: jkelly11@partners.org
Abstract
Scientific understanding of addiction as a chronic disorder has increased substantially in the past 15 years stemming from the results of several retrospective and prospective studies. This research has revealed that among individuals with severe alcohol and other drug problems periods of relapse and poor functioning are common over many years and even decades, despite the receipt of intermittent interventions. Because these interventions typically occur only following acute substance-related crises, treatment typically takes the form of acute biopsychosocial stabilization and is delivered in discrete, self-contained, programs that typically end the service relationship shortly after discharge with little focus on providing adequate linkage to continuing care or recovery support. The predominant acute care paradigm is insufficient and mismatched to the realities of the chronic illness of substance dependence. In this chapter, we provide an overview of recovery management (RM) and recovery-oriented systems of care (ROSC) as new guiding paradigms for the future treatment of, and recovery from, severe alcohol and other drug problems. We also summarize notable examples of RM and ROSC implementation efforts at the program, system, city, and state, levels. Results from these efforts provide a foundation for confident optimism that a cost-effective system of care can be successfully established that is well suited to managing the undulating and enduring risks associated with the chronic illness of substance dependence.
Keywords
Addiction recovery managementRecovery-oriented systems of careAddiction treatment systemsAlcoholics anonymousNarcotics anonymous
Introduction
Scientific understanding of addiction as a chronic condition that requires ongoing monitoring and intermittent management to achieve and maintain recovery has increased substantially in the past 15 years [1–5]. This has come about through the long-term retrospective, and increasingly, prospective study of individuals with substance-related conditions. Results have brought forth a clear realization that among those with substance dependence, especially severe dependence, and few recovery resources, periods of relapse and poor functioning are common over many years and even decades, despite the receipt of intermittent and various interventions [2, 3, 6–9]. These interventions typically occur only following an acute substance-related crisis. Consequently, care typically takes the form of acute biopsychosocial stabilization and symptom reduction. Furthermore, treatments are often delivered in self-contained programs, which typically end the service relationship shortly following discharge, with little sensitivity or time devoted to facilitating ongoing support to cope with the enduring environmental triggers and risks in the homes and communities in which patients live. Thus, adequate linkage to continuing care or recovery support is often lacking [10–12]. It is estimated that between 50 and 70% of individuals following a treatment episode will resume alcohol/drug use in the first year, most within the first 90 days [13]. Furthermore, 25–35% of patients treated in addiction programs will be readmitted within 1 year, and nearly 50% will be readmitted within 2–5 years [14–16]. These accumulating scientific findings echo the voice of recovery advocacy groups and amplify the experience of affected individuals and their families: the existing acute care paradigm is clearly insufficient and mismatched to the realities of the chronic illness of substance dependence.
In this chapter, we outline recovery management (RM) and recovery-oriented systems of care (ROSC) as new guiding paradigms for the future treatment of, and recovery from, severe alcohol and other drug problems (AOD). We begin by discussing briefly the nature of “recovery” on which the RM and ROSC approaches are based. We then describe the broad range of substance-related concerns and where RM and ROSC fit within this broader picture and provide a rationale for the necessary implementation of RM and ROSC. We end by summarizing some notable RM and ROSC real-world exemplars and their impact.
What is Recovery? Definition and Conceptual Boundaries
The term “recovery” is the organizing concept of this book and forms the paradigmatic basis for a “recovery management” approach. But what is recovery exactly? Defining addiction “recovery” is a challenging task that evokes passionate and wide-ranging opinion [17]. However, its current “conceptual fuzziness” [17] has not prevented its use as an organizing paradigm nor its integration into major consumer, advocacy, and federal agencies (e.g., SAMHSA/CSAT, 2006) including the National Institutes of Health [18]. Its increasingly widespread use and acceptance as an organizing concept has led to attempts in producing operational definitions (e.g., [17, 19]). While broad consensus has not been reached, several definitions have been proffered.
Multiple terms are used in the field to define improvement following AOD problems [20–23]. Perhaps the most commonly used are “sobriety,” “remission,” and “recovery.” It has been suggested that “sobriety” or “remission” might represent the elimination of problems from one’s life (e.g., individuals no longer meet DSM criteria for “abuse” or “dependence”), whereas the term “recovery” might convey, in addition to remission, a broader achievement of global health [24]. Thus, the former emphasizes what has been removed, and the latter what has been added to one’s life [17]. What does it mean when an individual states, “I’m in recovery”? Typically this means, “I am abstinent and I don’t want to use alcohol or other drugs anymore and I’m taking steps in my life to ensure that doesn’t happen.” Taken separately, constituent parts of this statement include current abstinence (presumably for at least a month or longer), a desire for continued abstinence, and a realization that in order for abstinence to persist, a variety of other activities must be pursued in order to support and facilitate it. Abstinence is the principal constituent and goal because without it little progress can be made, and reinstatement of the disorder is highly likely if the individual has suffered previously from dependence [25, 26]. Also, RM approaches that have focused explicitly and intensively on abstinence have been associated with remarkable long-term recovery rates [27]. However, there is an equally powerful realization that abstinence is unlikely to be maintained without ongoing engagement in supportive and rewarding activities that can compete effectively with substance use for time and attention. Engagement in such activities comes under the broad rubric of “recovery capital” [28, 29]. Unlike acute models of addiction care that focus on deficits and pathology, the RM and ROSC approaches assess and place greater emphasis on strengths, assets, and recovery capital. White [17] describes recovery as the experience of healing from addiction while actively managing a continued vulnerability to relapse and building a healthy, productive, and meaningful life [17].
RM and ROSC Within the Broad Range of Approaches to Substance-Related Problems
Substance-related problems and conditions are viewed as the number one public health problem in the USA [30]. These problems encompass a vast range of substance-related involvement and impairment ranging from mild and intermittent to chronic and severe. Thus, characterizing addiction as a chronic illness does not mean that all substance-related problems have a prolonged course, high potential for relapse, or require ongoing monitoring and management [31, 32]. Even diagnosed “substance use disorders” (both DSM IV “abuse” and “dependence [addiction]”) represent a huge range of substance involvement and impairment, and the syndrome of “dependence/addiction” itself possesses a graded intensity [26]. Substance-related conditions are marked also by their heterogeneity in cause, clinical course, physical and psychiatric comorbidities, and pathways to recovery [11, 31, 33–35]. In contradistinction to less severe or transient problems for which briefer, nonspecialty, interventions may suffice, RM and ROSC are best suited to treat that segment of the population for whom severe AOD problems tend to be chronic and who possess only limited recovery assets and resources.
The chronically relapsing course and harmful and hazardous health risks associated with severe addiction problems are analogous to other chronic medical illnesses, such as hypertension and diabetes. Thus, approaches to the management of these chronic disorders make sense and have intuitive appeal for the management of addiction [36]. Such sustained preventative and early detection/intervention approaches provide a valuable and fitting model to minimize the potentially harmful and frequently lethal consequences of addiction [3]. Such models do not wait for crises to occur, but rather attempt to avoid crisis through proactive monitoring and collaborative management of sobriety-based symptoms and relapse warning signs [37], as well as early reintervention if and when lapses do occur [3]. Recovery management (RM) and recovery-oriented systems of care (ROSC) approaches [11], based on a chronic disease conceptualization akin to the management of hypertension and diabetes, can help reduce the enormous burden of disease and prodigious social and economic costs associated with severe substance-related conditions by reducing reliance on costly, crisis driven, systems of care [27, 38–40].
As noted [31], the survival of specialty treatment for severe AOD problems as a social institution depends on the ability to move toward RM and ROSC. The current acute care treatment system has vastly oversold what can be achieved with regard to a given treatment episode (one addiction rehabilitation center even advertises its specific “cure rate” at “84.4%”). The mantra “treatment works” is as popular as it is vague, surviving through its rhetorical indistinctness. Consumers are more likely to see and experience alarmingly high rates of relapse following treatment, especially during the first 90 days post discharge [41–43]. While continuous abstinence is the exception, the reality is that treatment does produce substantial clinical improvements in continuous measures of change, such as the percent of days an individual is abstinent, increased lengths of continuous abstinence, and decreased intensity of use, in the months following a treatment episode. However, even these short-term gains often decay, especially for those most addicted and severely impaired and who have few recovery assets or resources. Yet, and as ludicrous as it may seem when exposed to the light of day, there remains an implicit expectation of a “cure” (i.e., lifelong full sustained remission) following a single episode of addiction care. Even the best addiction treatment evaluation scientists have been susceptible to the exaggerated potency of a single episode of care as measurements of addiction treatment effectiveness have typically taken place 6–12 months or longer following a single treatment episode [44]. This is an acute care model evaluation paradigm.
RM and ROSC are part of a larger shift toward a recovery paradigm reflected in the growth and diversification of recovery mutual aid groups, new recovery support institutions, and a new recovery advocacy movement that further reflects the cultural and political awakening of individuals and families in recovery. The addiction treatment industry has oversold the long-term recovery outcomes that can be achieved for people with severe AOD problems from a brief episode of professionally directed biopsychosocial stabilization. We believe the acute model of care is culturally, economically, and politically unsustainable. Flexible treatment approaches that are able to assess and build on individuals’ assets and strengths, as well as attend to deficits, and readily adapt to the variety in presentation and manage undulating relapse risk over the long term are deemed critical in order to provide appropriate levels of care at optimal times and thus maximize addiction treatment effectiveness and cost-efficiency.
The inability of our society to cope effectively with the immense burden of disease attributable to substance-related conditions using professional efforts alone has been reflected in the growth in number and size of addiction-specific mutual help organizations during the past 75 years [44–46]. Assertive linkage to communities of recovery through mutual-help groups (MHGs) [45, 47] represents important opportunities to sustain and potentiate treatment benefits. There have been eight rigorously conducted, randomized controlled trials of assertive linkage to mutual-help groups, such as Alcoholics Anonymous (AA), which have used twelve-step facilitation (TSF) approaches. Each of these studies reveals clinically meaningful gains for TSF over standard referral practices and when compared to cognitive behavioral therapy alone [47, 48]. These studies have used different methods including TSF as an independent, stand alone, addiction therapy (Brown et al. 2004) [48–50]; TSF integrated into an existing therapy (e.g., CBT) [50, 51]; TSF as an additional, but independent, group component of a treatment package [52, 53]; and TSF as a modular appendage used to enhance effective linkages to 12-step groups at the end of a standard treatment phase [54–56]. Such linkage epitomizes the type of synergism that can amplify and extend the effects of formal care by facilitating engagement with free, peer-led, community recovery resources. However, by itself, this type of RM intervention would represent an appendage or “additive,” rather than “transformative,” change [38].
Models of, and Benefits from, RM and ROSC Transformation and Implementation Initiatives
The process of transforming addiction treatment from an acute care model to a model of sustained recovery management is already underway as evidenced by federal, state, and local “systems transformation” efforts and growing calls for a recovery-focused research agenda to guide and support these transformation efforts. However, diffusion of innovations is notoriously slow. Certain factors are associated with more rapid diffusion. According to Rogers (2003) [57], diffusion of innovation is likely to be enhanced when (1) the innovation is seen by adopters to have “simplicity”, (2) there is an opportunity to “try it out” for a while before committing entirely (“trialability”), (3) there is an obvious “relative advantage” to the new innovation, (4) it makes an observable difference (“observability”) when implemented, and (5) it is compatible with existing practice and infrastructure (“compatibility”). When one compares the types of systems changes and innovations discussed and exemplified in RM and ROSC approaches, it is clear that these types of innovations are likely to take time, may be a long time, to disseminate, be adopted, and shape the delivery of service to the ultimate benefit of primary sufferers, their loved ones, and our broader society and public health. Yet, we believe that such changes are entirely necessary if addiction treatment as a social institution is to survive. Furthermore, as described in more detail below, the efforts of the city of Philadelphia, the state of Connecticut, and many other organizations highlight the fact that these changes are wholly possible, are beneficial on a broad scale, but are likely to require concerted and persistent effort and integrated approaches from multiple stakeholder groups.
The “observability” element in diffusion of innovation noted above means that not only is the implementation of evidence-based practices important within RM and ROSC but also measurement of process and outcomes. The vastness and complexity of systems changes mean that change will take time, but in the meantime, stakeholders will need to know that these efforts are having some actual real-world impact. For example, rates of treatment access, engagement, and retention should increase, and treated persons and their families at least should experience better outcomes and less suffering. Such changes also ultimately should lead to better stewardship of available resources and enhanced cost-efficiency through a lowered need for emergency/crisis care. Most important is the measurement of implementation and system change efforts. Without such measurement, the impact on patient outcomes of these large-scale undertakings will be assumed to be better, but unknown, with accountability absent. Further, without embedded measurement of processes and outcomes innovation will be stymied, as systems and practitioners within systems will be unable to assess the impact of their own innovations and adaptations to meet the recovery needs of their own patients or particular patient subgroups more effectively.
Adoption, Implementation, and Maintenance of RM and ROSC
There are now outstanding recent exemplars of RM and ROSC implementations [3, 27, 38, 40, 58–60]. These have taken place at the treatment system [3, 27, 59, 61], city [38], and state [39, 40] levels. Achara-Abrahams et al. [38] describe different levels of system change that can occur in ROSC that produce different impacts. The first is “additive” change, in which a component of RM and ROSC is added as an appendage (e.g., peer support services or telephone support services). While a step in the right direction, this level of change is unlikely to produce lasting changes, may be difficult to sustain in an otherwise acute care-oriented system, or produce large impacts. The second level of change is “selective,” in which certain programs or levels of care within a larger system undergo shifts to align themselves with a RM/ROSC orientation, while others do not. Although significant efforts are expended in the selective change approach, this type of change can result in service user and provider confusion and, ultimately, may introduce disintegrative forces. The third level is “transformative” level change in which the entire philosophical and practice basis of the system undergoes radical change. Below we summarize some of the documented benefits arising from the implementation of RM and ROSC at different levels of scale, beginning with treatment systems and followed by city and state level transformations.
Two of the most heavily evaluated examples of sustained RM approaches have been conducted through Recovery Management Checkups initiatives [3] and the Physician’s Health Program (PHP) [27]. Scott and Dennis [3] describe a ground-breaking five-point protocol for managing addiction as a chronic condition. The acronym “TALER” provides a summary of the protocol. It consists of (1) tracking, (2) assessing, (3) linking, (4) engaging, and (5) retaining. In order to provide ongoing assessment and intervention the patients’ whereabouts must be continually “tracked.” Second, valuable and reliable assessment instruments are needed to objectively “assess” which individuals need early reintervention. Third, “linkage” assistance helps motivate and link individuals to formal treatment or other recovery support services. Fourth, assertive follow-up helps ensure that after assessment, individuals actually “engage” in recommended services. Fifth, support for “retention” is needed to prevent early dropout, which is a major risk factor for relapse. The core RM assumption of this approach is that long-term monitoring and early reintervention facilitate early detection of relapse, reduce the time to treatment, and thus improve long-term outcomes. Scott and Dennis describe an iterative improvement process using “lessons learned” from the evaluation of earlier RM implementation efforts to improve TALER approaches. For example, they were able to substantially improve treatment linkage rates from 30 to 44% by adding transportation help for patients, and improve treatment retention rates from 40 to 62% by helping clinicians avoid unnecessary and premature discharges. Relative to those individuals not receiving TALER recovery management checkups (RMCs), those receiving them were significantly more likely to enter treatment sooner, to receive more treatment, experience more abstinent days, and spend less time in the community needing treatment. These findings indicate that using the TALER protocol, RMCs are able to more adeptly address the enduring and cyclical nature of substance dependence via ongoing monitoring and linkage to treatment.
A further study of RM implementation on a national scale has been conducted with physicians suffering from a substance use disorder (SUD) [27]. This is a further example of how early detection and intervention with physicians with SUD, coupled with high-quality treatment, extensive monitoring, and assertive linkage to ongoing abstinence-focused recovery support can produce impressive 5-year abstinence rates of 79% and return-to-work rates of 96%. This RM approach as noted by Skipper and Dupont [27] is based on eight components (1) finding a motivational fulcrum, (2) providing comprehensive initial assessment and extended treatment, (3) providing care management for many years, (4) having a high expectation for abstinence-based recovery, (5) assertively linking participants to recovery support groups, (6) sustaining monitoring and support, and, when necessary, reintervening, (7) reintervening at a higher level of intensity at any sign of relapse, and (8) integrating these elements, where possible, within a comprehensive program. This eight-point PHP program might be seen as a concise practical summary of the RM approach [32]. Given the broad range of substance involvement, impairment, and range of available recovery capital for physicians within this program, the PHP experience strongly suggests that “the limits of recovery from substance use disorders do not lie in the biology of the disease but in the context in which it is managed and treated” [27]. The PHP is perhaps the best evidence to date that high-quality, sustained, RM initiatives of this type can produce outstanding long-term rates of addiction remission and recovery.
A further study of RM and ROSC implementation was conducted across an entire behavioral health care system in the state of Illinois. Boyle et al. [61] initiated transformative level RM changes that included professional recovery coaches (RC). The RC model was based on a community case management model to help individuals build on their recovery assets and strengths. There are six essential components inherent in this model: (1) RC services are voluntary – based on clients’ willingness to meet. (2) Services are time-unlimited – service is delivered for as long as individuals need or want to receive them. (3) Services are community based – RC services are delivered primarily in the community, but treatment setting meetings can be conducted to help engage clients early. (4) The RC–client relationship is open-ended: Clients have the option of working with RCs after they complete, or if they withdraw early, from treatment. (5) Services are designed to reduce harm – RCs never stop working with clients because they become symptomatic and begin using substances. Rather, they attempt to link and reengage them with treatment or other peer-support services. (6) Services operate on the “Vegas Rule” – what is communicated to RCs stays with RCs and confidentiality is upheld. As of June 2009, 503 patients had enrolled in the new RC initiative. Preliminary evaluation research that examined proximal outcomes among enrolled women found that women who chose to receive ongoing support and treatment via a RC were significantly more likely both to engage in continuing care outpatient services (an explicit goal of the treatment continuum of care) and to stay engaged in treatment longer [61].
A more traditional but potent RM example has been the provision of ongoing recovery support and monitoring through residential recovery homes (e.g., Oxford Houses). These community-based, peer-led, residential resources have been shown to be highly cost-effective. Prospective research studies of the Oxford House model reveal that these resources are able to retain some of the most relapse-vulnerable individuals in a supportive living environment, minimizing relapse risk, while simultaneously building individuals’ recovery capital. In one experimental study, 150 individuals with SUD were randomly assigned either to live in an Oxford House or receive community-based aftercare services (Usual Care). At a 2-year follow-up, about one-third of participants assigned to the Oxford House condition reported substance use compared to nearly two-thirds of those assigned to Usual Care. Also, just over three-quarters of Oxford House participants were employed versus just under half of those assigned to Usual Care. Illegal activity among Oxford House participants during this follow-up was half that of Usual Care. Among women, compared to those receiving Usual Care, those entering Oxford Houses were substantially more likely to be deemed stable enough to regain custody of their children. Earning capacity was also greater among Oxford House participants who earned roughly $550 more per month than the participants in the Usual Care group resulting in an annualized productivity difference of approximately $494,000. The lower rate of incarceration among Oxford House participants compared with Usual Care participants resulted in annualized savings for the Oxford House sample of roughly $119,000. Together, productivity and incarceration benefits yielded an estimated $613,000 in savings accruing to Oxford House participation.
On a broader scale, Achara-Abrahams et al. [38] provide a detailed example of the processes, challenges, and benefits that resulted from the transformative level change undertaken in the city of Philadelphia. The city undertook large-scale initiatives to transform its behavioral health care system. Preliminary results from these broad-ranging efforts indicated that populations with serious behavioral health conditions were experiencing substantially improved quality of life, were participating in the community at increased levels, and utilizing emergency care at significantly lower levels. Also, cost efficiencies were demonstrated as a result of the provision of recovery-oriented care. Provider agencies implementing integrated peer- and professionally led services experienced increased higher retention rates in the magnitude of 50% to over 75% [38].
Perhaps most ambitiously, Connecticut has conducted a transformative, state-level, initiative to redesign its entire public/private behavioral healthcare system treating approximately 100,000 individuals annually, producing some compelling results. This transformation resulted in a 62% decrease in use of acute inpatient services and a 78% increase in use of ambulatory services while simultaneously experiencing 14% lower annual costs, even after adding extensive recovery-support services, such as housing and transportation. There was also an increase in access by 40% for first time admissions, while experiencing a simultaneous 24% decrease in average annual costs per client. This decrease was even larger for high service users [39]. As a further piece of this transformational level change effort within the state of Connecticut, community-based peer recovery support services have made an impact on the receipt of continuing care for individuals leaving treatment. In 2009, for example, 268 volunteers contributed almost 15,000 h of service mostly within the walls of Connecticut’s recovery community centers. Almost 37,000 outbound calls were made through telephone recovery support calls to 1,420 individual recovering persons. The peer-based continuing care initiative provided the equivalent of nearly $400,000 in service provision [40], and is likely to result in significantly improved remission and recovery rates for those individuals in receipt of these services [62, 63].
Deepening and Broadening the Transformation to RM and ROSC
As cultural shifts in treatment conceptualization and service system delivery occur at multiple levels, the reach of ROSC is beginning to broaden and deepen to address the needs of special populations (e.g., young people; dually diagnosed) and settings (e.g., rural areas) and to make use of new computer and Web-based technologies (e.g., self-assessment and recovery monitoring; online support groups).
From a life course perspective, it is adolescents and emerging adults who are at the highest risk to encounter AOD problems [64], and it is during this life stage that SUD has its onset in nearly all cases. Yet, surprisingly, this age group has received comparatively little attention and has remained drastically underserved. Given that early detection and early intervention in almost every disease or disorder increases the chances of early remission and a better prognosis for recovery, including in addiction [2], a broadening of RM and ROSC approaches to address this highest risk segment of the population is likely to yield considerable subsequent public health benefit. Because these young people are often the least intrinsically motivated to seek and remain in treatment, proactive assertive outreach and screening in work places, colleges and schools, and primary care settings are most likely to detect cases and begin the treatment process earlier, thereby preventing long-term problems [2]. There have been increasing initiatives for screening, brief intervention, and referral to treatment (SBIRT) that are designed specifically for this purpose [65, 66]. Clinical collaboration with employers and employee assistance programs and criminal justice can provide a “motivation fulcrum” [27] that can aid treatment retention, which has been shown to improve rates of SUD remission.
The use of technology has been shown to improve the quality and effectiveness of health care and reduce related costs. However, the adoption and implementation of computerized assessment and monitoring systems in health arenas lags far behind that in other business community sectors. In the management of severe AOD problems, this medium is rarely used but has the potential for broad reach in risk assessment, providing automated individualized feedback, and for providing ongoing support and monitoring of relapse risk following an index episode of stabilization. The emergence too of online addiction recovery support groups means 24/7 access to supportive communities globally either to augment or, for some, replace professional and peer-led face-to-face recovery support contact. Such Web-based programs and resources may be invaluable in rural area where access to recovery support services is limited.
Conclusions
Perceptions of the possibility of long-term recovery from the chronic illness of addiction have been pessimistic and even nihilistic. This perception has been perpetuated by a pervasive treatment mismatch between an acute care delivery system and its attempts to treat a chronic condition. These examples of, and results from, RM and ROSC implementation efforts paint a discernibly more hopeful and optimistic picture of what can be achieved when concepts and practices converge and are aligned to fit the true chronic and complex nature of addiction. Transformation efforts to RM and ROSC take time to achieve and, as work in the State of Connecticut and City of Philadelphia illustrate, will involve sustained processes of conceptual alignment, practice alignment, and contextual alignment (policy, regulation, funding mechanism, and stakeholder relationships). However, while undoubtedly challenging, we believe such efforts to be vital. The future of addiction treatment as a social institution may rest with this ability or inability to align itself with a model of sustained recovery management.
References
1.
Cunningham J. Untreated remission from drug use: the predominant pathway. Addict Behav. 1999;24:267–70.PubMedCrossRef
2.
Dennis M, Scott C, Funk R, Foss M. The duration and correlates of addiction and treatment careers. J Subst Abuse Treat. 2005;28:s51–62.PubMedCrossRef
3.
Scott C, Dennis M. Recovery Management Checkups with Adult Chronic Substance Users. In: Kelly JF, White W, Editors. Addiction Recovery Management: Theory, Research and Practice. New York, NY: Springer Science and Business Media; 2011.
4.
McLellan AT. Have we evaluated addiction treatment correctly? Implications from a chronic care perspective. Addiction. 2002;97(3):249–52.PubMedCrossRef
5.
Hser Y, Anglin D. Addiction Treatment and Recovery Careers. In: Kelly JF, White W, Editors. Addiction Recovery Management: Theory, Research and Practice. New York, NY: Springer Science and Business Media; 2011.
6.
Brown SA, Ramo D, Anderson K. Long-term trajectories of adolescent recovery. In: Kelly JF, White W, Editors. Addiction Recovery Management: Theory, Research, and Practice. New York, NY: Springer Science and Business Media; 2011.
7.
Hser Y, Longshore D, Anglin MD. The life course perspective on drug use: a conceptual framework for understanding drug use trajectories. Eval Rev. 2007;31:515–47.PubMedCrossRef
8.
Moos R, Schutte K, Brennan P, Moos B. Older adults’ alcohol consumption and late-life drinking problems: a 20-year perspective. Addiction [serial online]. 2009;104(8):1293–302.
9.
Vaillant G. The natural history of alcoholism revisited. Cambridge, MA: Harvard University Press; 1995.
10.
McKay JR. The role of continuing care in outpatient alcohol treatment programs. In: Galanter M, editor. Recent developments in alcoholism: services research in the era of managed care. New York, NY: Plenum Publishing; 2001. p. 357–73.
11.
White WL. Recovery management and recovery-oriented systems of care: scientific rationale and promising practices. Pittsburgh, PA: Northeast Addiction Technology Transfer Center, Great Lakes Addiction Technology Transfer Center, Philadelphia Department of Behavioral Health/Mental Retardation Services; 2008.
12.
Godley M, Godley S, Dennis M, Funk R, Passetti L. The effect of assertive continuing care on continuing care linkage, adherence and abstinence following residential treatment for adolescents with substance use disorders. Addiction. 2007;102(1):81–93.PubMedCrossRef
13.
Hser Y, Grella C, Chou C, Anglin M. Relationships between drug treatment careers and outcomes: findings from the National Drug Abuse Treatment Outcome Study. Eval Rev [serial online]. 1998;22(4):496–519.CrossRef
14.
Simpson DD, Joe GW, Fletcher BW, Hubbard RL, Anglin MD. A national evaluation of treatment outcomes for cocaine dependence. Arch Gen Psychiatry. 1999;56:507–14.PubMedCrossRef
15.
Simpson DD, Joe GW, Broome KM. A national 5-year follow-up of treatment outcomes for cocaine dependence. Arch Gen Psychiatry. 2002;59:539–44.
16.
Brown SA, Ramo DE. Clinical course of youth following treatment for alcohol and drug problems. In: Liddle HA, Rowe CL, editors. Adolescent substance abuse: research and clinical advances. Cambridge, NY: Cambridge University Press; 2006. p. 79–103.CrossRef
17.
White WL. Addiction recovery: its definition and conceptual boundaries. J Subst Abuse Treat. 2007;33(3):229–41.PubMedCrossRef
18.
Substance Abuse and Mental Health Services Administration. Results from the 2005 National Survey on Drug Use and Health: National findings. (NSDUH Series H-30, DHHS Publication No. SMA 06-4194). Rockville, MD: Office of Applied Studies; 2006.
19.
Betty Ford Institute Consensus Panel. What is recovery? A working definition from the Betty Ford Institute. J Subst Abuse Treat. 2007;33:221–8.CrossRef
20.
Kelly JF. Evidence for adolescent participation in Alcoholics Anonymous and Narcotics Anonymous: further steps needed. Brown Univ Dig Addict Theory Appl. 2004;23:31.
21.
Kelly JF, Westerhoff C. Does it matter how we refer to individuals with substance-related problems? A Randomized study with two commonly used terms. Int J Drug Policy. 2010;21(3):202–7.PubMedCrossRef
22.
Milgram G. The need for clarity of terminology. Alcohol Treat Q [serial online]. 2004;22(2):89–95.CrossRef
23.
Substance Abuse and Mental Health Services Administration. National Survey of Substance Abuse Treatment Services (N-SSATS): 2003. Data on Substance Abuse Treatment Facilities, Office of Applied Studies. DASIS Series: S-24, DHHS Publication No. (SMA) 04–3966. Rockville, MD: Office of Applied Studies; 2004.
24.
CSAT. Definitions and terms relating to co-occurring disorders. COCE Overview Paper 1 (DHS Publication No. (SMA) 06-4163). Rockville, MD: Substance Abuse and Mental Health Services Administration and Center for Mental Health Services; 2006.
25.
Koob GF, Le Moal M. Neurobiology of addiction. New York, NY: Elsevier; 2006.
26.
Edwards G. The alcohol dependence syndrome: a concept as stimulus to enquiry. Br J Addict. 1986;81:171–83.PubMedCrossRef
27.
Skipper GE, DuPont RL. The Physician Health Program: A Replicable Model of Sustained Recovery Management. In: Kelly JF, White W, Editors. Addiction Recovery Management: Theory, Research and Practice. New York, NY: Springer Science and Business Media; 2011.
28.
Cloud W, Granfield R. Natural recovery from substance dependency: lessons for treatment providers. J Soc Work Pract Addict [serial online]. 2001;1(1):83–104.CrossRef
29.
Granfield R, Cloud W. Social context and ‘natural recovery’: the role of social capital in the resolution of drug-associated problems. Subst Use Misuse [serial online]. 2001;36(11):1543–70.CrossRef
30.
Schneider Institute for Health Policy. Substance abuse: the nation’s number one health problem. Princeton, NJ: Robert Wood Johnson Foundation; 2001.
31.
White and Kelly, this volume.
32.
White W, McLellan AT. Addiction as a chronic disease: key messages for clients, families and referral sources. Counselor. 2008;9:24–33.
33.
Hesselbrock V, Hesselbrock M. Are there empirically supported and clinically useful subtypes of alcohol dependence? Addiction [serial online]. 2006;101 Suppl 1:97–103.
34.
Jellinek EM. The disease concept of alcoholism. New Haven, CT: Hillhouse; 1960.CrossRef
35.
Moss HB, Chen CM, Yi H. Prospective follow-up of empirically derived alcohol dependence subtypes in wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC): recovery status, alcohol use disorders and diagnostic criteria, alcohol consumption behavior, health status, and treatment seeking. Alcohol Clin Exp Res. 2010;34(6):1–11.CrossRef
36.
McLellan AT, Lewis DC, O’Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA. 2000;284:1689–95.PubMedCrossRef
37.
Gorski T, Miller M. Staying sober: a guide for relapse prevention. Staying sober workbook: A serious solution for the problem of relapse. Independence. Missouri: Herald House/Independence Press; 1992.
38.
Achara-Abrahams I, Evans A, King J. Recovery-Focused Behavioral Health System Transformation: A Framework for Change and Lessons Learned from Philadelphia. In: Kelly JF, White W, Editors. Addiction Recovery Management: Theory, Research and Practice. New York, NY: Springer Science and Business Media; 2011.
39.
Kirk TD. Connecticut’s Journey to a Statewide Recovery-Oriented Healthcare System: Strategies, Successes and Challenges. In: Kelly JF, White W, Editors. Addiction Recovery Management: Theory, Research and Practice. New York, NY: Springer Science and Business Media; 2011.
40.
Valentine P. Peer-Based Recovery Support Services within a Recovery Community Organization.–The CCAR Experience. In: Kelly JF, White W, Editors. Addiction Recovery Management: Theory, Research and Practice. New York, NY: Springer Science and Business Media; 2011.
41.
Hunt WA, Barnett LW, Branch LG. Relapse rates in addiction programs. J Clin Psychol. 1971;27(4):455–6.PubMedCrossRef
42.
Brown SA. Recovery patterns in adolescent substance abuse. In: Marlatt GA, Baer JS, editors. Addictive behaviors across the life span: prevention, treatment, and policy issues. Newbury Park, CA: Sage Publications, Inc; 1993. p. 161–83.
43.
Tims FM, Dennis ML, Hamilton N, Buchan BJ, Diamond G. Characteristics and problems of 600 adolescent cannabis abusers in outpatient treatment. Addiction. 2002;97:46–57.PubMedCrossRef
44.
Kelly JF, Yeterian JD. Mutual-help groups. In: O’Donohue W, Cunningham JR, editors. Evidence-based adjunctive treatments. New York, NY: Elsevier; 2008. p. 61–105.CrossRef
45.
Humphreys K. Circles of recovery: self-help organizations for addictions. Cambridge: Cambridge University Press; 2004.
46.
White W. The mobilization of community resources to support long-term addiction recovery. J Subst Abuse Treat. 2009;36:146–58.PubMedCrossRef
47.
Kelly JF, Yeterian JD. The role of mutual-help groups in extending the framework of treatment. Alcohol Res Health. in press.
48.
Project MATCH Research Group. Project MATCH (Matching Alcoholism Treatment to Client Heterogeneity): rationale and methods for a multisite clinical trial matching patients to alcoholism treatment. Alcohol Clin Exp Res. 1993;17(6):1130–45.CrossRef
49.
Brown BS, O’Grady KE, Farrell EV, Flechner IS, Nurco DN. Factors associated with frequency of 12-Step attendance by drug abuse clients. American Journal of Drug and Alcohol Abuse, 2001;27(1):147–160.
50.
Litt MD, Kadden RM, Kabela-Cormier E, Petry NM. Changing network support for drinking: network support project 2-year follow-up. J Consult Clin Psychol. 2009;77(2):229–42.PubMedCrossRef
51.
Walitzer KS, Derman KH, Barrick C. Facilitating involvement in Alcoholics Anonymous during out-patient treatment: a randomized clinical trial. Addiction. 2009;104:391–401.PubMedCrossRef
52.
Kaskutas L. Alcoholics anonymous effectiveness: faith meets science. J Addict Dis [serial online]. 2009;28(2):145–57.CrossRef
53.
Kaskutas L, Subbaraman M, Witbrodt J, Zemore S. Effectiveness of making Alcoholics Anonymous easier: a group format 12-step facilitation approach. J Subst Abuse Treat. 2009;37(3):228–39.PubMedCrossRef
54.
Timko C, DeBenedetti A, Billow R. Intensive referral to 12-step self-help groups and 6-month substance use disorder outcomes. Addiction. 2006;101(5):678–88.PubMedCrossRef
55.
Timko C, DeBenedetti A. A randomized controlled trial of intensive referral to 12-step self-help groups: one-year outcomes. Drug Alcohol Depend. 2007;90(2–3):270–9.PubMedCrossRef
56.
Kahler C, Read J, Stuart G, Ramsey S, McCrady B, Brown R, et al. Motivational enhancement for 12-step involvement among patients undergoing alcohol detoxification. J Consult Clin Psychol. 2004;72:736–41.PubMedCrossRef
57.
Rogers EM. Diffusion of innovations. 5th ed. New York, NY: Free Press; 2003.
58.
Boyle M, Loveland D, George S. Implementing Recovery Management in a Treatment Organization. In: Kelly JF, White W, Editors. Addiction Recovery Management: Theory, Research and Practice. New York, NY: Springer Science and Business Media; 2011.
59.
Jason LA, Olson BD, Mueller DG, Walt L, Aase DM. Residential recovery homes/Oxford Houses. In: Kelly JF, White W, Editors. Addiction Recovery Management: Theory, Research and Practice. New York, NY: Springer Science and Business Media; 2011.
60.
Kirk TD. Connecticut’s Journey to a Statewide Recovery-Oriented Healthcare System: Strategies, Successes and Challenges. In: Kelly JF, White W, Editors. Addiction Recovery Management: Theory, Research and Practice. New York, NY: Springer Science and Business Media; 2011.
61.
Boyle M, Loveland D, George S. Implementing Recovery Management in a Treatment Organization. In: Kelly JF, White W, Editors. Addiction Recovery Management: Theory, Research and Practice. New York, NY: Springer Science and Business Media; 2011.
62.
McKay JR. Is there a case for extended interventions for alcohol and drug use disorders? Addiction. 2005;100:1594–610.PubMedCrossRef
63.
McKay JR. Continuing Care and Recovery. In: Kelly JF, White W, Editors. Addiction Recovery Management: Theory, Research and Practice. New York, NY: Springer Science and Business Media; 2011.
64.
Substance Abuse and Mental Health Services Administration. Results from the 2008 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-36, HHS Publication No. SMA 09-4434). Rockville, MD; 2009.
65.
Substance Abuse and Mental Health Services Administration. National Registry of Substance Abuse Programs and Practices. Washington, DC: US Department of Health and Human Services; 2008.
66.
Madras B, Compton W, Avula D, Stegbauer T, Stein J, Clark H. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend [serial online]. 2009;99(1–3):280–95.CrossRef