Originally posted on the CPDD blog 12/19/2011
‘Recovery’ is increasingly becoming the guiding vision of substance abuse services and policy. SAMHSA (funder of publicly funded services) is promoting the multi-system Recovery Oriented System of Care (ROSC) model and both the President’s Drug Strategy and the Department of Education are calling for the expansion of recovery supports across community-based settings. In this context, Recovery is understood as an ongoing process through which one achieves abstinence, wellness and improved quality of life.
Recovery oriented initiatives strive to be evidence based. Yet the science of recovery remains in its infancy in spite of the size of the population concerned: Rough estimates peg at least 20 million as the number of Americans who consider themselves in sober, stable recovery. Speaking at the launch of the privately-funded National Quit and Recovery Registry, NIDA’s Dr. Volkow stated that ‘Most of the research that has been done up to now has focused on that immediate intervention that would allow a person to stop taking drugs. Much less is known about recovery.’
Having devoted the past decade of my research career to elucidate the recovery experience, I could not agree more. As I noted in 2007, most scientific articles whose title bears on recovery actually measure only short-term abstinence.
Here are highlights of a monograph detailing some key obstacles to building the necessary science of recovery, based on our experience seeking NIH funding for recovery oriented studies. The NIH funding process has historically favored relatively short-term evaluations of professionally driven interventions designed to reduce symptoms among individuals recruited in limited settings- i.e. treatment. That is, addiction research has mirrored the substance use service delivery paradigm that uses an acute care model to address a chronic condition. The approach isn’t optimally suited to promote/support recovery, nor is it adequate to build the evidence basis needed to inform recovery focused services and policy.
– It’s believed that most people recover without treatment yet recruiting non treatment recovery samples makes reviewers nervous: it’s challenging to determine (retrospectively) whether they were ever ‘addicts’ based on self-report that are difficult to corroborate (we’ve tried). I.e., there is no true ‘baseline.’
– Recovery support services are ‘non-clinical’- i.e., often peer driven and organically developed; reviewers’ requests for manualization and fidelity of interventions are challenging to address.
– Sample representativeness (external validity) is difficult to address because of the lack of data on the exact size, demographics, clinical history and recovery path of recovery community. Treatment population data are inadequate to infer the representativeness of a recovery sample but often the best we currently have.
Throughout the ages and across cultures today, human beings have sought chemical means of altering their moods and a small proportion becomes ‘addicted’. Substance use and addiction aren’t going away. Recovery is here to stay; it’s increasingly driving federal agencies’ initiatives. Our science (and funding for said science) must catch up to the experience and needs of the individuals we seek to help. Key research questions include:
– Specifically what are the key ingredients of recovery- abstinence plus what?
– How do we measure this for services’ internal monitoring and external accountability purposes?
– How is recovery attained when treatment isn’t sought?
– Which services/supports are needed at which stage of recovery and by whom?
– How effective and cost effective are the various forms of recovery supports?
– How can recovery supports be better integrated in primary health care settings and community based venues? Where are they most effective?
– How can we harness the strength of the recovery community to build a workforce of recovery supports as healthcare reform will identify/insure more individuals needing services?
– What constitute barriers to recovery and to seeking recovery supports – especially stigma, policy and lack of awareness that recovery is attainable?
Elucidating and promoting a wellness process that unfolds over years, organically, in the community, requires that we ask different questions, using different methods and measuring different outcomes than when studying short-term, professionally driven symptom reduction interventions delivered in specialty care settings. There’s no urine tox screen for recovery…That does not mean scientific standards ought to be compromised but the boundaries of science must be expanded to allow for wellness processes to be understood. We owe the nation a scientific basis to inform recovery-oriented services and policy.