Recovering to Recovery Among Adolescent Youth

Marks K.R., Leukefeld C.G.

There is a growing need for research on women recovering from nonmedical prescription opioid use. A paradigm shift is to focus on wellness and factors that support, rather than hinder, recovering women. For example, although physical health is impacted by nonmedical prescription opioid use, improved health may be a strength-based factor among recovering women. The aim of this preliminary study was to examine physical health in a recovering framework as women begin recovering from nonmedical prescription opiate use.This study conducted secondary data analysis using self-report data from Kentucky's Targeted Assessment Program (TAP). TAP assesses and provides pretreatment for problems impeding work or interfering with parental responsibilities. Data included 1247 adult women reporting a history of nonmedical prescription opioid use and receiving pretreatment. Bivariate and logistic regression analyses examined whether physical health and access to health services at baseline were associated with substance-related behavior change upon completion of pretreatment.Women reporting better physical health and fewer days with no activities due to health barriers were more likely to engage in pretreatment substance-related behavior change [χ2(8) = 34.6, p < 0.05]. However, ∼40% of women reported barriers in accessing healthcare.Using a recovering framework, women's physical health, as expected, is associated with engagement in pretreatment substance-related behavior change. Ongoing service coordination with practitioners and medical providers should be incorporated into care to meet the need. Future research should continue to examine factors that support recovering women, using a recovering framework.

Bougard K.G., Laupola T.M., Parker-Dias J., Creekmore J., Stangland S.

Evidence-based group therapy in an inpatient setting that provides an integrated treatment approach for both trauma and addiction in female adolescents.The purpose of this evidence-based practice (EBP) project was to implement and assess the impact of an integrated group therapy approach for both posttraumatic stress disorder (PTSD) and substance use disorder (SUD) in adolescent females as part of a residential treatment program.The Iowa Model of EBP guided this EBP project. Judith Herman's three-stage model of trauma recovery and the Skills Training in Affective and Interpersonal Regulation (STAIR) model served as the theoretical framework for the group therapy curriculum. Two programs, Seeking Safety, by Lisa Najavits and VOICES, by Stephanie Covington, provided a guide for group topics and activities.Patients that participated in Turning the Tides© group therapy curriculum reported a decrease in overall PTSD symptoms and decreased functional impairment scores, based on the Child PTSD Symptoms Scale. However, there was a statistically significant increase in the use of as needed medications following the completion of group therapy. Postgroup evaluations from patients indicated a genuine desire to engage in the group therapy as well as an increased sense of trust with facilitators. Implications for psychiatric nursing include the delivery of safe, quality patient care as evidenced by positive improvement in patient outcomes.

Glaude M., Torres L.R.

Warren J.C., Smalley K.B., Barefoot K.N.

Volkow N.D., Koob G.F., McLellan A.T.

This article reviews scientific advances in the prevention and treatment of substance-use disorder and related developments in public policy. In the past two decades, research has increasingly supported the view that addiction is a disease of the brain. Although the brain disease model of addiction has yielded effective preventive measures, treatment interventions, and public health policies to address substance-use disorders, the underlying concept of substance abuse as a brain disease continues to be questioned, perhaps because the aberrant, impulsive, and compulsive behaviors that are characteristic of addiction have not been clearly tied to neurobiology. Here we review recent advances in the neurobiology of addiction to clarify the link between addiction and brain function and to broaden the understanding of addiction as a brain disease. We review findings on the desensitization of reward circuits, which dampens the ability to feel pleasure and the motivation to pursue everyday activities; the increasing strength of conditioned responses and stress reactivity, which results in increased cravings for alcohol and other drugs and negative emotions when these cravings are not sated; and the weakening of the brain regions involved in executive functions such as decision making, inhibitory control, and self-regulation that leads to repeated relapse. We also review the ways in which social environments, developmental stages, and genetics are intimately linked to and influence vulnerability and recovery. We conclude that neuroscience continues to support the brain disease model of addiction. Neuroscience research in this area not only offers new opportunities for the prevention and treatment of substance addictions and related behavioral addictions (e.g., to food, sex, and gambling) but may also improve our understanding of the fundamental biologic processes involved in voluntary behavioral control. In the United States, 8 to 10% of people 12 years of age or older, or 20 to 22 million people, are addicted to alcohol or other drugs. 1 The abuse of tobacco, alcohol, and illicit drugs in the United States exacts more than $700 billion annually in costs related to crime, lost work productivity, and health care. 2-4 After centuries of efforts to reduce addiction and its related costs by punishing addictive behaviors failed to produce adequate results, recent basic and clinical research has provided clear evidence that addiction might be better considered and treated as an acquired disease of the brain (see Box 1 for definitions of substance-use disorder and addiction). Research guided by the brain disease model of addiction has led to the development of more effective methods of prevention and treatment and to more informed public health policies. Notable examples include the Mental Health Parity and Addiction Equity Act of 2008, which requires medical insurance plans to provide the same coverage for substance-use disorders and other mental illnesses that is provided for other illnesses, 5 and the proposed bipartisan Senate legislation that From the National Institute on Drug Abuse (N.D.V.) and the National Institute of Alcohol Abuse and Alcoholism (G.F.K.) — both in Bethesda, MD; and the Treatment Research Institute, Philadelphia (A.T.M.). Address reprint requests to Dr. Volkow at the National Institute on Drug Abuse, 6001 Executive Bld., Rm. 5274, Bethesda, MD 20892, or at nvolkow@ nida . nih . gov.

Chung T., Sealy L., Abraham M., Ruglovsky C., Schall J., Maisto S.A.

Among youth in substance use treatment, peer substance use consistently predicts worse treatment outcomes. This study characterized personal (egocentric) networks of treated youth and examined predictors of adolescents' motivation and perceived difficulty in making changes in the peer network to support recovery.Adolescents (aged 14-18; N = 155) recruited from substance use treatment reported on substance use severity, motivation to abstain from substance use, abstinence goals such as "temporary abstinence," motivation and perceived difficulty in reducing contact with substance-using peers, and personal network characteristics. Personal network variables included composition (proportion of abstinent peers) and structure (number of network members, extent of ties among members) for household and nonhousehold (peer) members.Although a majority of peer network members were perceived as using alcohol or marijuana, youth in treatment had relatively high motivation to abstain from substance use. However, treated youths' motivation to reduce contact with substance-using peers was relatively low. In particular, a goal of temporary abstinence was associated with lower motivation to change the peer network. For marijuana, specifically, network composition features (proportion of abstinent peers) were associated with motivation and perceived difficulty to change the peer network. For marijuana, in particular, network structural variables (extent of ties among members) were associated only with perceived difficulty of changing the peer network.Despite high motivation to abstain from substance use during treatment, adolescents reported low motivation to reduce contact with substance-using peers. Personal motivation to abstain and abstinence goal predicted motivation to reduce contact with substance-using peers. In contrast, particularly for marijuana, network structure predicted perceived difficulty of network change. Results highlight the potential utility of addressing motivation and perceived difficulty to change the peer network as part of youth network-based interventions.

Kaskutas L.A., Ritter L.A.

This article addresses the assumption that pathways to recovery from substance abuse and dependence, and the language used to define one’s relationship to substances, translate to actual beliefs and behaviors in terms of substance use. We draw on social representation theory and use data from a large web-based study ( N = 9,341) whose goal was to understand how individuals in recovery define what recovery means to them. We often hear people say that they are “in recovery,” and present findings now provide empirical evidence of the prevalent meanings of this ubiquitous expression. The belief that recovery is abstinence was broadly held in our sample, especially among those exposed to treatment and 12-step self-help groups and who define themselves as in recovery—and most (but not all) of such individuals are complete abstainers (no alcohol or drugs). In contrast, among the “self-changers” who did not attend treatment or self-help groups, the most common self-definition was used to have an alcohol or drug problem but don’t any more, half of whom believe that recovery is abstinence while half do not, and only one third are abstainers. Findings are of public health relevance, as it is estimated that among American adults alone, 10% report having had alcohol or drug problems but no longer do. In line with the central concepts of social representation theory, people’s pathways to recovery have a strong effect on how they define themselves and their behaviors and beliefs, but it is not universal.

Leukefeld C.

Rosenblatt R.A., Andrilla C.H., Catlin M., Larson E.H.

Bouton M.E.

Unhealthy behavior is responsible for much human disease, and a common goal of contemporary preventive medicine is therefore to encourage behavior change. However, while behavior change often seems easy in the short run, it can be difficult to sustain. This article provides a selective review of research from the basic learning and behavior laboratory that provides some insight into why. The research suggests that methods used to create behavior change (including extinction, counterconditioning, punishment, reinforcement of alternative behavior, and abstinence reinforcement) tend to inhibit, rather than erase, the original behavior. Importantly, the inhibition, and thus behavior change more generally, is often specific to the "context" in which it is learned. In support of this view, the article discusses a number of lapse and relapse phenomena that occur after behavior has been changed (renewal, spontaneous recovery, reinstatement, rapid reacquisition, and resurgence). The findings suggest that changing a behavior can be an inherently unstable and unsteady process; frequent lapses should be expected. In the long run, behavior-change therapies might benefit from paying attention to the context in which behavior change occurs.

Brown S., Tracy E.M., Jun M., Park H., Min M.O.

We examined the experiences of women in treatment for substance dependence and their treatment providers about personal networks and recovery. We conducted six focus groups at three women’s intensive substance abuse treatment programs. Four coders used thematic analysis to guide the data coding and an iterative process to identify major themes. Coders identified social network characteristics that enabled and impeded recovery and a reciprocal relationship between internal states, relationship management, and recovery. Although women described adding individuals to their networks, they also described managing existing relationships through distancing from or isolating some members to diminish their negative impact on recovery. Treatment providers identified similar themes but focused more on contextual barriers than the women. The focus of interventions with this population should be on both internal barriers to personal network change such as mistrust and fear, and helping women develop skills for managing enduring network relationships.

Botzet A.M., McIlvaine P.W., Winters K.C., Fahnhorst T., Dittel C.

Accurate evaluation and documentation of the efficacy of recovery schools can be vital to the continuation and expansion of these beneficial resources. A very limited data set currently exists that examines the value of specific schools established to support adolescents and young adults in recovery; additional research is necessary. The following article outlines the methodology utilized in a current quasi-experimental study evaluating both academic and therapeutic outcomes of adolescents attending recovery high schools as compared to traditional (non-recovery-based) high schools. The developmental considerations in assessing adolescents in recovery and their parents is delineated in this article, which underscores the need for extensive knowledge of adolescent substance abuse and other mental health issues. In addition, sensitivity around privacy among adolescents, parents, schools, and health providers is highlighted, as well as the validity of assessment. Key assessment strategies, including protocol of recruitment and interviewing techniques, are also presented along with a list of parent and adolescent assessment instruments and their corresponding interpretive variables. Protocol recommendations for future research are also outlined.

Moberg D.P., Finch A.J., Lindsley S.M.

This article reviews findings from the authors' studies of recovery high schools (RHS), including a 1995 program evaluation of a school in New Mexico (Moberg and Thaler, 1995), a 2006-09 descriptive study of 17 recovery high schools (Moberg and Finch, 2008), and presents early findings from a current study of the effectiveness of recovery high schools. Descriptive and qualitative findings are presented. The focus is on characteristics of RHS students and, in light of those student characteristics, findings regarding academic and recovery support programming in recovery high schools.

Finch A.J., Moberg D.P., Krupp A.L.

Knudsen H.K., Staton-Tindall M., Oser C.B., Havens J.R., Leukefeld C.G.

Women involved in the criminal justice system, particularly those with a history of drug use, are at elevated risk of HIV infection, yet few HIV prevention interventions have been tailored for delivery to incarcerated women. Drawing on the Relational Model, the Reducing Risky Relationships for HIV (RRR-HIV) intervention was developed and evaluated in a multisite randomized clinical trial. Women with weekly drug use prior to incarceration (n = 444) who were incarcerated within correctional institutions in four states were randomized to (1) the RRR-HIV intervention consisting of an HIV educational video, five group sessions, and one postrelease booster session or (2) a control condition consisting of the HIV educational video. The RRR-HIV intervention combined didactic and interactive content regarding seven "thinking myths" about intimate relationships that may result in decisions to engage in risky sexual behaviors. Data were collected while women were still incarcerated and approximately 90 days following release from prison by trained interviewers. A negative binomial regression (NBR) model of unprotected sexual behaviors at the 90-day follow-up indicated that RRR-HIV participants reported fewer unprotected sexual behaviors than women in the control condition once the analysis was adjusted for study site. Future studies should examine the sustainability of the RRR-HIV intervention's effect on risk reduction. Implementation research is needed to determine whether delivery of this intervention by correctional staff or peers, rather than research staff, yields similar reductions in unprotected sexual behaviors.

Eekhoudt C.R., Sandhu M., Mniszak C., Goodyear T., Turuba R., Marchand K., Barbic S., Fast D.

Despite extensive literature exploring the harms associated with illicit substance use among young people who use drugs (YPWUD), the concept of "recovery" among this population has received significantly less attention. Addressing this literature gap can inform efforts to better support YPWUD as they pursue their goals.

Becker S.J., Shiller H., Fan Y., DiBartolo E., Olson M.B., Casline E., Wijaya C., Helseth S.A., Kelly L.M.

The continuing care period following residential substance use treatment is a time when adolescents are at especially high risk for relapse, yet few families engage in traditional office-based care. Parent SMART (Substance Misuse among Adolescents in Residential Treatment) is a multi-component continuing care intervention for parents that combines three digital health technologies - an "off the shelf" online parenting program, daily phone notifications, and an online parent networking forum - with support from a parent coach. The current study solicited both qualitative and quantitative user feedback about Parent SMART to ensure responsivity to user preferences, refinement, and continuous improvement of the intervention.

Helseth S.A., Scott K., Escobar K.I., Jimenez F., Becker S.J.

Background: Parents of adolescents in residential substance use (SU) treatment face a myriad of barriers to continuing care services. Growing research suggests that mobile health (mHealth) technologies can overcome common barriers to continuing care services, yet no work has addressed parents' needs. To gain insight into parents' continuing care needs, we analyzed online forum posts made by parents who received a novel mHealth intervention. Methods: Thirty parents received access to an online networking forum where they could connect with our adolescent SU expert or the community of parents also navigating their adolescent's post-discharge transition. In real-time, participants could ask questions and share information, experiences, and emotional support. Results: Twenty-one parents (70%) posted at least once; 12 parents made 15 posts to our expert, while 18 parents made 50 posts to the parent community. Thematic analysis uncovered five major themes: parenting skills; parent support; managing the post-discharge transition; adolescent SU; and family functioning. Conclusions: Parents discussed a range of topics directly and indirectly related to their adolescent's treatment. Incorporating networking forums into mHealth continuing care interventions offers parents a secure space to ask questions, share concerns, and gather information needed to support their adolescent's transition home.