Treating Opioid AddictionPresented byChip Abernathy, LPC, CAC

Increase in Opioid Usage: Heroin

Significant increase in Opioid Usage in U.S. in past two decades

• Treatment admissions for heroin steadily increased 1992-2008

• Increase in heroin purity- able to sniff or smoke it vs. IV use

• More young people using it, thinking less addictive if not IV

Increased in Opioid Usage: RxPain:5th Vital Sign

Also, around 1997, pain was identified as

‘5th vital sign’ - more people being appropriately treated for pain - significantly more opioids being prescribed

• More opioid-related problems: OD, death, addiction

• Treatment admissions for opioid pain reliever addiction increased more than fourfold between 1998 and 2008

U.S. Worker Positive Urine Tests, 1999 and 2009

1999 2009

U.S. Annual Total Opioid Rx 1998-2002

Annual Numbers (in Millions) New Non-medical Users of Opioids (12 or Older)

U.S. Rx Opioid Deaths 2001-2005

What Do We Do About This?

We’ve got to do something.

Treatment of Opioid AddictionTwo Distinctly Different Approaches

The two most prevalent approaches:

•Drug Substitution Treatment, which is also called ‘medication-assisted treatment’ in the U.S.

•Abstinence-Based Treatment, in which total abstinence following a brief detox is the goal

Both have ‘evidence-based’ data to support their positions

History/Trends

Drug Substitution Treatment

Heroin: Touted As Both a Cough Suppressant and A ‘Non-Addictive Substitute’ for Morphine - 1895

Heroin AdHeroin ad

1914 Harrison Anti-Narcotic ActAct of Congress - used registration and taxation to restrict

use of opiates and cocaine for legitimate medical purposes. Use of opioids went from uncontrolled access under Federal law to access controlled by physicians.

The Harrison Act was interpreted to mean that opioids could not be used for the treatment of opioid addiction.

The Harrison Act has had a far-reaching effect on addiction and its treatment that continues to this day.

A Lot of Opiate Addicts in America in the 1920’s

U.S. Public Health Service research concluded that there were 110,000 to 150,000 opiate addicts in the U.S. in 1920’s (U.S. population in 1920 was approximately 118,000,000). That’s around 10% of the U.S. population.

A specialized hospital for the treatment of addicts was suggested.

Nyswander and Dole and Methadone Maintenance - 1960’s

1963 Nyswander and Dole, physicians, were early advocates of methadone maintenance

Based on Lexington and Ft. Worth federal government treatment data, other studies of the day, and personal opinion - boldly proclaimed that large numbers of opioid addicts were:

incapable of enduring abstinence and that narcotics maintenance was the only viable treatment

option for large numbers of addicts.

According to this view, addicts needed narcotics the way diabetics needed insulin: to achieve normal metabolic functioning.

Methadone – 1970’s - Politics and Crime Reduction

1970’s large numbers of methadone clinics open - Nixon’s 1972 re-election campaign - cut down on crime caused by heroin use

Most methadone clinics were breeding grounds for drug activity.

Methadone BenefitsMethadone Maintenance Therapy (MMT) has been around

for over 45 years and has been well-researched. Studies have shown that MMT

reduces illicit drug use; improves health in many cases; advances personal, academic and workplace

functionality; increases treatment retention; and reduces chances of accidental overdose (although

methadone OD rate has been dramatically increasing in recent times).

Methadone Adverse Events Since 1997

On a national level, as reported to the FDA, methadone-related adverse events

increased nearly 1800% between 1997 and 2004; fatalities increased 390% from 1999 to 2004 (the

most recent national data available), and methadone was the drug with the greatest

increase in fatalities; methadone also is the sixth most frequently suspected drug in death and serious nonfatal outcomes.

Drug Abuse Treatment Act - 2000The Drug Abuse Treatment Act of 2000 now allows doctors to prescribe Suboxone® and Subutex®, both opioids, from their offices for the treatment of opioid addiction

... and thus amend the Harrison Act of 1914.

Suboxone® The active ingredient in Suboxone is buprenorphine, a partial

opioid agonist. It also contains naloxone, an opioid antagonist to discourage people from dissolving the tablet and injecting it.

Suboxone may be used to • reduce illicit opioid use• help patients stay in treatment

by• suppressing symptoms of opioid withdrawal• decreasing cravings for opioids

Additional Buprenorphine Benefits Short-term buprenorphine use is helpful for

detoxification from other opiates. For those wishing to remain on buprenorphine

indefinitely, that is an option. Buprenorphine can be prescribed by a local doctor in the

privacy of his or her office and can be obtained from a local pharmacy, whereas methadone must be obtained from a methadone clinic (OTP) and quite often on a daily basis.

There is less chance of overdose with buprenorphine than with methadone.

Drug Substitution Treatment - Harm Reduction

Drug Substitution Treatment in the U.S. is considered a harm reduction approachtapering doses of methadone or Suboxone®/Subutex® opioid maintenance.

Helps to: reduce the spread of HIV/AIDS/hepatitis; reduce illicit drug use; increase treatment retention; reduce crime to attain drugs; improve employability, improve family relations.

Drug Substitution Treatment Today

Drug Substitution Treatment, or Medication-Assisted Treatment if you prefer, is a popular method of treatment in the U.S. and abroad.

In the U.S. people are treated either with

• methadone or with Suboxone®

In Europe • heroin is also used, especially for those who do not

do well on Methadone Maintenance Treatment.

In both the U.S. and abroad, counseling is recommended with substitution treatment.

Support for Drug Substitution Treatment in the U.S.

Drug Substitution Treatment is advocated for in the U.S. by most of the large organizations that deal with addiction including:

•National Institute of Drug Abuse (NIDA)

•Substance Abuse and Mental Health Services Administration (SAMHSA)

•American Society of Addiction Medicine (ASAM)

•National Association of Alcoholism and Drug Abuse Counselors (NAADAC)

Incongruence

NIDA, SAMHSA, ASAM, and NAADAC advocate abstinence-based treatment for all DSM IV substance dependence disorders

•except opioid dependence, in which drug substitution treatment is considered appropriate treatment

For example, it would not be considered appropriate treatment (by most) to prescribe and maintain alcoholics on a substitution sedative/hypnotic drug such as Xanax, tell them to go to meetings and counseling, and consider that being in recovery.

Drug Substitution Support Groups

Since there are inherent problems with trying to have people on drug substitution blend with people in abstinence-based 12 Step programs, such as NA/AA, I would suggest that anyone prescribing substitution drugs either:Provide professionally facilitated support groups for these patients Know of where such groups exist and encourage their patients to attend

History/Trends

Abstinence-based treatment

Disease and Recovery The philosophy of this approach to addiction counseling

incorporates two important elements: Endorsement of the disease model The spiritual dimension of recovery

These elements differentiate the approach from some other forms of treatment and reflect the influence of 12 Step philosophy.

Treatment Philosophy

Addiction is a complex brain disease that damages the addict physically, mentally, and spiritually.

All of these areas need to be addressed in treatment to

support recovery.

Living a Life In RecoveryThe skills necessary for long-term recovery are all directed at

finding meaning and purpose in life.

Recovery is… A way of thinking, a way of acting, and a way of relating to

others. It is a philosophy of living. It requires the daily effort of working a recovery program.

SpiritualityThe element of spirituality is very general and not specific to

any religion.

The spiritual component implies that there is healing in one’s life that needs to take place abstinence from the drug is merely the first step in that

process rather than the ultimate goal.

A Higher PowerThe spiritual element of treatment also involves…

encouraging a holistic perspective on the individual, and suggests that recovery involves

a return to self-respect through honesty with oneself and others, and

having a belief in or sense of connection to something greater than oneself.

More Focused and Overtly Stated

Within addiction counseling, the role of spirituality in healing tends to be more focused and overtly stated than in most other therapeutic orientations.

Characteristics of Addiction

Substance dependence (addiction) is a disease which is Incurable Chronic Progressive Relapsing Potentially fatal if not treated

Addiction is a very treatable disease with success rates about the same as other chronic illnesses such as asthma, diabetes and hypertension.

An Old Abstinence-Based ApproachIn the late 1800’s to early 1900’s ‘treatment’ of opiate

addiction consisted of treatment of withdrawal symptoms. This took the forms of:

• just abruptly stopping use• step down with one week of drug of choice and then

stop• prolonged withdrawal ranging from weeks to months.

Various agents were used in the process including such things as cannabis, strychnine, belladonna, atropine, cocaine, quinine, whiskey, and even coffee.

Drug Laws Create Increase in Crime1920’s U.S. Federal Penitentiaries were overcrowded due to the Harrison Act. Two thirds of the inmates in Atlanta, Leavenworth and McNeill Island prisons were there for addiction-related crimes.

Addicts used illicit drugs, doctor-shopped, forged prescriptions, and became proficient at faking pain (prescriptions for narcotics were ok for pain but not for addiction). Then/now: Same/same

‘Narcotics Farms’In 1929 Congress approved two ‘narcotics farms’ (later named

U.S. Public Health Narcotics Hospitals)

• to relieve the overcrowding of federal prisons

• for the housing and rehabilitation of addicts/offenders who had been convicted of federal narcotics laws.

The Lexington, KY facility was opened in 1935 for addicts east of the Mississippi and the Ft. Worth, TX facility was opened in 1938 for addicts west of the Mississippi. These were early abstinence-based treatment facilities.

Both facilities eventually stopped treatment of addiction.

‘Narcotics Farm’

Later Named U.S. Public Health Narcotics Hospital

Lexington, KY

U.S. Narcotics Farm Entrance

Treatment at Lexington and Ft.WorthTwo populations were treated at Lexington and Ft. Worth – mandated federal prisoners and voluntary admissions. The

mandated people stayed anywhere from one to several years and the voluntary people could sign out at any time.

Treatment included detox, farming or manufacturing work (payment was in

cigarettes), group and individual therapy, experimental treatment methods, 12 Step meetings, school, church, and vocational training.

There was four times more work than therapy.

Treatment Outcome Studies at Lexington and Ft. Worth90% to 96% of treated addicts returned to active opiate addiction

within 6 months of release from the federal narcotics hospitals. A more positive way of saying it is that 4% to 10% of these addicts did not return to active opiate addiction within 6 months following treatment.

Some saw this as treatment failure and some saw it as comparable to outcome studies of other chronic diseases of the day such as TB, arthritis, hypertension and diabetes.

Many saw this as fuel for the fire of prevailing public opinion that relapse was a conscious choice of moral weaklings.

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Relapse Rates are Similar for Addiction and Other Chronic Illnesses (JAMA 2000)

McLellan et al., JAMA, 2000.

Minnesota ModelThe 1940’s and 1950’s brought the ‘Minnesota Model’ of

treatment for alcohol and other drug dependence. This model of treatment blended

abstinence-based treatment professional, multidisciplinary treatment team 12 Step Program philosophy education about addiction as a primary, chronic, treatable

bio-psycho-social disease therapy/counseling for alcoholics and other addicts therapy/counseling for families aftercare planning involving ongoing AA/NA involvement

AA Comes To Be in the 1930’sBill W., a stockbroker, and Dr. Bob S., a physician meet on

Mothers’ Day, 1935 in Akron, OH and AA begins.

One by one, through carrying the message that recovery is possible, the fellowship begins with a handful of members.

The Basic Text of AA, ‘The Big Book’, is published in 1939.

Dr. Bob and Bill W.

Co-founders of Alcoholics Anonymous

NA Comes to Be in the 1950’s1953 Narcotics Anonymous as it exists today began in

Southern California. NA uses AA’s 12 Steps and 12 Traditions (with permission of AA) with minor wording changes:

Step 1 ...powerless over alcohol (AA) ... over our addiction (NA). Tradition 12 ... carry the message to alcoholics (AA) ... to addicts (NA).

NA has grown from a fledgling membership in the 1950’s and ‘60’s to a continuously growing membership that today has over 58, 000 groups spanning the globe.

Jimmy K

Co-founder of Narcotics Anonymous

AA/NA Membership History1939 – AA begins with 100 members - after the Big Book (AA’s

basic text) is published the year ends with 2000 members due to publicity re: book

1941 – Saturday Evening Post article about AA helps to increase membership to 6000

1947 – Star-Telegram of Ft. Worth Texas reports that AA has reduced war industries worker absenteeism due to alcoholism and has helped 5000 workers return to their jobs

1953 – AA’s Twelve Steps and Twelve Traditions is published, membership is approximately 100,000

AA/NA Membership History1953 – Narcotics Anonymous as it exists today begins in

southern California with a handful of members1970 – NA groups worldwide number 701970’s and 1980s - Minnesota Model treatment produced a

significant increase in AA and NA membership.1976 – AA increases to 28,000 groups in 92 countries, with

membership totaling more than one million (1,000,000).

AA/NA Membership History2000 – AA Membership tops two million (2,160,013) - number

of groups for the first time surpasses the 100,000 mark

2005 – AA’s Twenty-Five Millionth copy of the Big Book, Alcoholics Anonymous, presented to warden of San Quentin Prison. The first A.A. meeting in San Quentin was held in 1941.

2009 – NA Membership Survey notes over 58,000 groups – roughly half as many groups as AA, in 131 countries - based on AA group/member ratio, NA membership is estimated at greater than one million

Narcotics Anonymous Evidence That Abstinence/12 Step Recovery Is Effective

2009 Narcotics Anonymous Membership Survey of 11,723 members years drug-free were:

<1 year - 12%

1-5 years - 33%

6-10 years-18%

11-15 yrs.-13%

16-20 yrs.-12%

>20 years-12%

Project MATCH and VA Study Show Evidence That Abstinence/12 Step Recovery - with Assistance - is Effective Project MATCH, a large (1,726 participants) study of abstinence-based approaches to treat alcoholism compared three approaches: Motivational Interviewing, Cognitive Behavioral Therapy, and Twelve Step Facilitation.

All three were found to be effective

At one year follow-up, all three had similar outcomes

At three year follow-up, Twelve Step Facilitation had more favorable results for sustained abstinence

VA Study of 2,045 substance abuse patients showed that increased involvement in AA/NA meetings, reading NA/AA literature, working the 12 steps, and having a sponsor improved outcomes and that treatment providers encouraging these activities significantly improved their likelihood of occurring

Minnesota Model Treatment ChallengesMinnesota Model treatment is expensive time consuming and often takes more than one course of

treatment to help addicts get to the point of having sustainable recovery

These are some of the same challenges facing treatment of any chronic illness.

Most Believe Recovery Includes Abstinence and MoreThe vast majority (84.9%) of recovering addicts studied and cited

in a 2007 Journal of Substance Abuse Treatment article indicated that total abstinence is necessary for recovery. Study participants also included recovery to include a new life (22%); well-being (13%); a process of working on yourself (11.2%); living life on life’s terms (9.6%); self-improvement (9%); learning to live drug-free (8.3%); recognition of the problem (5.4%); and getting help (5.1%).

A recurrent theme was that recovery is going back, regaining an identity (a self) lost to addiction.

Terrence Gorski Gorski’s CENAPS Model of treatment is an abstinence-based treatment model that incorporates relapse prevention, recovery as a developmental process, and utilizing 12 Step involvement.

This model helps patients and providers have a clearer understanding of what is to be accomplished with abstinence-based treatment and recovery.

Beliefs Upon Which Gorski’s Developmental Model of Recovery (DMR) are Based

1. Recovery is a long-term process that is not easy.

2. Recovery requires total abstinence from alcohol and other drugs, plus active efforts towards personal growth.

3. There are underlying principles that govern the recovery process.

4. The better we understand these principles, the easier it will be for us to recover.

Beliefs Upon Which Gorski’s DMR are Based ( Continued)

5. Understanding alone will not promote recovery; the understanding must be put into action.

6. The actions that are necessary to produce full recovery can be clearly and accurately described as recovery tasks.

7. It is normal and natural to periodically get stuck on the road to recovery. It is not whether you get stuck that determines success or failure, but it is how you cope with the stuck point that counts.

First Stage of Recovery: TransitionTransition stage: Theme: Giving up the need to control drug

use. Starts while the addicted person is still using. The tasks that need to be accomplished in order to consider the transition stage complete are:

1. Development of motivating problems

2. Failure of normal problem solving

3. Failure of controlled use strategies

4. Acceptance of the need for abstinence and the need for help

Transition Stage - NA Step One, Tradition ThreeAn addict must see a need to stop using before they have a desire to stop

using.

Tradition Three: The only requirement for membership is a desire to stop using. NA Basic Text:

“An addict who does not want to stop using will not stop using. They can be analyzed, counseled, reasoned with, prayed over, threatened, beaten, or locked up, but they will not stop until they want to stop. The only thing we ask of our members is that they have this desire. Without they are doomed, but with it miracles will happen.” (p. 63)

NA: First Step: We admitted we were powerless over our addiction, that our lives had become unmanageable.

Second Stage of Recovery: Stabilization

Stabilization Stage: theme: recuperating from damage caused by addictive use. This stage IS the stage in which opioid addicts present some special challenges and opportunities for providers to give much-needed help. The tasks to accomplish in the stabilization stage are:

physically recover from acute withdrawal and learn to manage post acute withdrawal.

learn to manage addictive preoccupation. learn to manage stress, emotions, and problems. resolve any crises well enough to focus on recovery develop hope and motivation.The stabilization stage of recovery can be particularly

challenging due to the severity of stress caused by Post Acute Withdrawal and Addictive Preoccupation.

Special Considerations in Treating Opiate Addicts

After stopping using, opiate addicts commonly experience… Discomfort of body, mind and spirit Vivid using dreams, drug cravings Depression (esp. depressed mood, anhedonia) and anxiety Strong urge to abort treatment due to discomfort of early

abstinence

Address Patients’ Discomfort and Any Co-Occurring Disorders

Treatment outcomes improve if the patient’s general discomfort associated with early abstinence and any co-occurring mental health problems that may be present are addressed early during treatment.

Abstinence-based treatment of opioid addiction can be just as successful as abstinence-based treatment for any other substance.

Post Acute Withdrawal and Addictive Preoccupation

Post Acute Withdrawal Syndrome starts after acute withdrawal ends. This syndrome often lasts for several months.

Symptoms include difficulty with… Thinking clearly Remembering Stress management Emotion management Sleeping restfully Physical coordination

Addictive Preoccupation is a type of delusional thinking associated with being a sober addict/alcoholic and includes…

Euphoric recall (recalling only the positives about using)

“Awfulizing” sobriety (focusing on only the negatives about sobriety)

Magical thinking about future use (thinking using will somehow make things better)

Left unattended, this becomes obsession, compulsion and craving.

Management of Post Acute Withdrawal and Addictive Preoccupation

Some things that are helpful for management of Post Acute Withdrawal include, but are not limited to, …

Having a structured lifestyle Getting enough rest Healthy diet and eating habits Regular exercise Social support, esp. AA/NA Deep-breathing relaxation skills Emotion management skills Conflict management skills H.A.L.T. – Don’t get too

Hungry, Angry, Lonely or Tired.

In addition to 12 step program coping skills, such as calling on others and a Higher Power, some things that are helpful for managing Addictive Preoccupation include, but are not limited to, …

Euphoric recall – Force yourself to remember specific negative experiences involving using.

“Awfulizing” sobriety – Force yourself to consider positive things about recovery.

Magical thinking about future use – Force yourself to consider what would actually happen if you used.

Teach Craving ManagementTeaching opiate addicts to manage cravings is essential in the

early days of recovery (during the stabilization stage).

Early introduction to NA/AA meetings/members is crucial. The NA Basic Text states: “We feel that our approach to the disease of addiction is completely realistic for the therapeutic value of one addict helping another is without parallel.”

How to Manage CravingsAccept that you are having a craving, and tell yourself that

although it is uncomfortable, it is normal and will pass

Let another recovering addict know that you have an urge to use – call your sponsor or someone else in NA/AA whom you know and trust – and talk about it

Just sit with it, pray for your H.P. to remove your urge to use, and no matter what, don’t use; it will pass. Tell yourself something like: “Just because I want to use doesn’t mean I have to act on it.”

Utilize Addictive Preoccupation Identification and Management along with 12 Step practices noted here.

NA/AA is Especially Important During the Stabilization StageDirect newly recovering people to NA meetings and members or ‘addict-friendly’ AA meetings.

Minnesota Model, CENAPS, Matrix, Twelve Step Facilitation - either state or imply that the 12 Step Program is the primary agent of change in recovery.

Doctors, nurses, therapists, counselors, others involved, can be remarkably helpful in facilitating a person finding a new way of life through this approach.

Stabilization Stage and Steps“Regardless of who we are, where we came from, or what we have done, we are accepted in NA. Our addiction gives us a common ground for accepting one another.” - NA Basic Text

NA Step Two: We came to believe that a power greater than ourselves could restore us to sanity.

NA Step Three: We made a decision to turn our will and our lives over to the care of God, as we understood him.

In the atmosphere of recovery found at meetings, addicts find a way to incorporate the first three Steps well enough into their lives and are then ready to move on to the later stages of recovery and more in-depth Step work.

Third Stage of Recovery: Early

Early Stage: theme: Internalization of addiction, what that means, and how to develop a recovery program that will be sustainable. This and all the remaining stages are the same for opioid addicts as they are for people addicted to alcohol, stimulants, or any other drugs. The tasks that need to be accomplished in early recovery are…

Full conscious recognition of addictive disease Full acceptance and integration of the addiction Learning non-chemical coping skills Short-term social stabilization Developing a sobriety-based value system

Fourth Stage of Recovery: Middle

Middle Recovery: Dealing with life as it occurs, sticking with the Program no matter what, and finding balance.

Resolving the demoralization crisis (Continuing to work the program even when it’s very difficult)

Repairing addiction-caused social damage Establishing a self-regulated recovery program Establishing lifestyle balance – including establishing and

maintaining relationships in and out of 12 Step program Management of change

Fifth Stage of Recovery: Late

Late Recovery: growing beyond childhood limitations. The tasks that need to be accomplish in late recovery are…

Recognizing the effects of childhood problems on sobriety Learning about family-of-origin issues Conscious examination of childhood Application to adult living Change in lifestyle

The Relapse-Prone Styleof Coping with Stuck Points

Denial and Evasion(The relapse-prone style)

Evade/deny the stuck pointStressCompulsive behaviorAvoid othersProblems escalateEvade/deny new problems

The Recovery-Prone Style of Coping with Stuck Points

Recognition and Problem Solving

(The recovery-prone style)

Recognize a problem exists

Accept that it is OK to have problems

Detach to gain perspective

Ask for help

Respond with action when prepared

Sixth and Final Stage of Recovery: Maintenance

Maintenance Stage: Balanced living and continued growth and development. The tasks that need to be accomplished in the maintenance stage are…

Maintain a recovery program Effective day-to-day coping Continued growth and development Effective coping with life transitions

Coping with Stuck Pointsin Recovery - GorskiAll recovery people will get stuck in recovery from time to

time. Getting stuck in recovery is neither good nor bad; it simply is.

Those who are successful in recovery cope with stuck points through a process of recognition and

problem solving learn how to recognize they are having a problem and are

stuck in their recovery accept that this is OK, knowing that as fallible human

beings, everyone reserves the right to not have all the answers.

detach from the problem and seek help from othersFinally, when they are prepared, they take responsible action.

Has the Definition of Recovery Changed? Before Suboxone and its widespread support from entities such

as NIDA, SAMHSA and ASAM, most treatment providers agreed that abstinence from addictive drugs was necessary for recovery.

Most addiction treatment providers understood that abstinence alone did not constitute recovery, but have believed for a long time that a prerequisite for recovery was that addicts/alcoholics had to stop using alcohol and other drugs, and do the other things necessary to consider themselves as being ‘in recovery’.

Drug Substitution Treatment vs. Abstinence-Based Treatment

With the substantial increase in the use of Suboxone in the past few years there has been and continues to be considerable debate in the treatment community about what constitutes being in recovery from opioid addiction.

Is a person ‘in recovery’ from opioid addiction while using an opioid drug - methadone, buprenorphine (U.S), and also including heroin (Europe)?

Attempt to Define Recovery: Drug Substitution Treatment

Drug Substitution Treatment advocates would likely define recovery as

reduced usage improved functioning retention in treatment reduced cravings stopping illicit use

Attempt to Define Recovery: Abstinence-Based Treatment

Abstinence-Based Treatment advocates would likely define recovery as

• sustained total abstinence from alcohol and other drugs

• improved functioning• demonstrated commitment to lifestyle changes

necessary to maintain abstinence and restore health physically, mentally and spiritually.

Ready, Willing and AbleWhen making a decision about whether an abstinence-based

treatment program is the right approach for an opiate addict, the those involved need to help the opioid addict decide…Am I

ready willing able

enough, to be uncomfortable during the early days of stopping opioid use in order to have a drug-free life? A person’s motivation will quite often be related to their perception of alternatives.

What Does Recovery Mean To You?The idea of ‘recovery’ has become popular in our culture but it is

ill-defined and poorly understood.

There is no real consensus among government agencies such as NIDA, SAMHSA and others that deal with substance use disorders about what constitutes recovery. That fact hinders clinical practice, research effectiveness, and research outcome interpretation.

As a treatment provider, it is important to answer the question: ‘What does recovery mean to me?’

Principles of the 12 StepsThe primary spiritual principles often associated with each

corresponding step of the 12 Steps …

1. Honesty 7. Humility

2. Hope 8. Love

3. Faith 9. Discipline

4. Courage 10. Perseverance

5. Integrity 11. Awareness

6. Willingness 12. Service

References Alcoholics Anonymous. Alcoholics Anonymous (The Big Book, third edition).

New York: Alcoholics Anonymous World Services Office, 1976.Alcoholics Anonymous. aa.org. AA history. Accessed 1-7-11.Alford, D.P., Liebschutz, J., Jackson, A., Siegel, B. Prescription drug abuse: An

introduction. Massachusetts NIDA Consortium, NIDA Centers of Excellence for Physicians Information: November 8, 2009

Bonetta, L. Study supports methadone maintenance in therapeutic communities. NIDA Notes, v. 23 (3): Dec 2010

Center for Substance Abuse Research (CESAR). Percentage of positive employee drug tests containing marijuana and cocaine decreases; sedatives, amphetamines and opiates increases. CESAR Fax, v. 19 (46): Nov. 29, 2010

Center for Substance Abuse Treatment (CSAT). Client’s Handbook: Matrix Intensive Outpatient Treatment for People With Stimulant Use Disorders. DHHS Pub. No. (SMA) 06-4154. Rockville, MD: SAMHSA, 2006

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French, M., Salomé H., Singular J., McAllen A.T. TrustBenefit-Cost Analysis of Addiction Treatment: Methodological Guidelines and Empirical Application Using the DATCAP and ASI Health Serv Res. 2002 April; 37(2): 433–455.  PMCID: PMC1430361. Copyright © 2002 Health Research and Education

Gorski, T.T. Passages Through Recovery: An Action Plan for Preventing Relapse. Center City, MN: Hazelden, 1989.

Gorski, T.T. Staying Sober: A Guide for Relapse Prevention. Independence, Missouri: Independence Press: 1986.

Lanier, W.L., Kharasch, E.D., Contemporary clinical opioid use: Opportunities and challenges. Mayo Clin Proc>v. 84(7): Jul 2009

Leshner, A.I. Addiction is a Brain Disease. Issues in Science and Technology Online, 2001.

Laudet, A.B. What does recovery mean to you? Lessons from the recovery experience for research and practice. J Subst Abuse Treat. 2007 October; 33 (3): 243-256. Accessed at PubMedCentral, 7-2010.

Laudet, A.B.; White, W.A. Recovery capital as prospective predictor of sustained recovery, life satisfaction and stress among former poly-substance users, Subt Use Misuse, 2008; 43 (1): 27-54. Accessed at PubMedCentral, 7-2010

References

McLellan et al. JAMA, 2000.

Mularski, R.A., et al. Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Intern Med, v. 21(6): June 2006

NA Way Magazine. Gathering for the 30th. April 2010, Vol. 27, Number 3, www.an.org

National Institute on Drug Abuse, NIH Pub.No.99-4380. An individual drug counseling approach to treat cocaine addiction: The collaborative cocaine treatment study model. Therapy Manuals for Drug Abuse, Manual 3, Mercer, DE, Woody, GE, Sept, 1999

Narcotics Anonymous World Service Office. Narcotics Anonymous (The Basic Text, fourth edition). Van Nuys, CA: World Service Office, Inc., 1987.

Owen, P. Minnesota model: Description of counseling approach. NIDA. http://archives.drugabuse.gov. Accessed 11-26-10.

Personal Communication. Anonymous addicts who have been on methadone and Suboxone and doctors who prescribe Suboxone, 2006 to 2010.

References Quest Diagnostics. U.S. worker use of prescription opiates climbing,

shows Quest Diagnostics drug testing index. News from Quest Diagnostics, September 16, 2010

Substance Abuse and Mental Health Services Administration (SAMSHA). buprenorphine.samhsa.gov/ Accessed 1-16-11.

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SAMHSA,, Office of Applied Studies. Misuse of Prescription Drugs:  Discussion: Substantive Findings and Methodological Issues and Challenges from the National Survey on Drug Use and Health (NSDUH) on the misuse of prescription psychotherapeutic drugs: 2008.

SAMHSA, Overview of opioid treatment programs within U.S. www.oas.samhsa.gov: 2008.

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U.S. Drug Enforcement Administration, Title 21, Section 812. Schedules of controlled substances. http://www.justice.gov/dea/pubs/csa/812.htm

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