I believe in you. [laughter] im happy. Im feeling terrific. Im still feeling happy and healthy and terrific so, alright, what i can see here, and maybe you can gather around here. You can see what im seeing. So, what i was going to tell you is this, ok . Been reflecting because its almost 50 years since the declaration of the war on drugs happened under nixon. Then as was declared some of you may remember or you can still see on youtube, is next in declaring the war on drugs and drug abuse as public enemy number one. And the story i wanted to tell you today was how weve come from the rhetoric that stands, the harsh rhetoric and harsh stance on the war on drugs, the very nature of that terminology and that rhetoric, of course, implies what . It implies a militaristic identifiable target. Out, although that was the initial stance to be tough on drugs, tough on crime, weve moved from that in the last 50 years towards a broader thec Health Approach to drug problem. If you look at the laws that have been passed to the antidrug abuse act of 1986, these laws were very harsh rhetoric laws designed to be tough on crime, tough on drugs. The result of that, of course, was what . It was an increase in the risen population. It worked in terms of locking people up. 4. 1 of the worlds population, but 25 of the worlds prisoners in the united states. It won theue and say war of drugs. It did not. That recognition of the more punitive stance resulted in the passing of laws to instead of looking at supply reduction only or more focused on supply reduction was also focusing on demand reduction. Prevention treatment and recovery. Think about the laws that have been passed in the last 20 years. The Affordable Care act, which necessitated Substance Abuse disorder was a required benefit. It had to be covered. That was a big shift. The comprehensive addiction and recovery act has been passed. Idea is to focus not just on supply reduction but also demand reduction. I had the privilege of being invited to the first ever reform summit held at the white house in 2013. Greta caskey, the director at the time. That really was underscoring and making a market shift, National Policy shift away from the rhetoric of the war on drugs towards a broader public Health Approach. So in some ways, weve gone from the war on drugs to the war on the war on drugs. Thate should also remember the war on drugs, when it was declared back in the 1970s, also marked an effort in terms of forging new ground in terms of treatment and prevention and recovery. In 1970. Founded the National Institute of drug abuse was founded in 1974. Of all the research thats been funded over the last 50 years, weve learned a lot about addiction, both in terms of cause and controllability. Weve learned a lot about genetics. That just likeow other complex illnesses or complex disorders from which people can suffer, Substance Abuse disorder is also a genetically abused disorder. Thats very clear. Thats resulted in the research and the funding supporting that research. We also, in terms of cause and controllability, these two factors were so pervasive in addiction. We understand also from the neuroscience findings, particularly the last 30 years through brain injury and neuroscience, that the controllability to regulate the impulse to use substances, which is the essential, despite consequent is, the essential cardinal feature of addiction, is the ability to regulate those impulses, have been clarified through our research on neuroscience. We can see much more clearly now what actually happens in the brain. In the subcortical areas and cortical areas of the brain. How those areas are radically repaired by chronic exposure to substances. Again, had, think about just the last 50 years, particularly the last 30 years, weve seen changes in our clinical approaches. Weve had recognition of the stages of change. Remember the stages of change . Precontemplation, contemplation, decision, preparation, action, and maintenance. And the treatments designed to address the note of ambulance ambivalence people often experience. I do and i dont. Its great when im a clinician, as well. People say im ready to go. Tell me what to do and ill do it. Those are wonderful cases to work with because theyll do whatever you say. But most people are coming in because of the police, because of their spouse, because of their family, because of school. Im here but i dont really want to be here. Yes, i do and i dont. So what did we used to say . Go away and come back when youre ready. You could be dead by them. By then. So, the motivational interviewing paradigm, which started in the early 1990s, was very important because it said look, we cant just say go away and come back later. If ambivalence is a cardinal feature of addiction, and we need to help patients resolve that end of lens. So it made it a clinician problem. How do we as clinicians then do something different, to really listen . Theres a good adage on the slide. Attest about what people really need is a good listening tool. Not so much a good talking tool. Police to think what people need is a good talking to. But instead, motivation interviewing the paradigm said what people really need is a good listening tool. Lets see the world through empathy, try to see the world through their eyes. Weve had also contingency management, good medications that can help people with alcohol and opioid abuse disorder. But what i want to get to is this notion of longterm recovery and the focus on longterm recovery that has taken shape. And the reason why this has been a focus, weve talked about addiction as a chronic illness for a long time, but weve not treated as such. Please treated it as an acute illness. Mcclellan. Chuck , who haveilliam white had the privilege of working with and publishing several papers in a book on Recovery Management. Who,e was really the guy he was really the architect of the chronic disease management, or chronic Recovery Management paradigm. He provided it a lot of the terminology with how we think about addressing addiction as a chronic illness. That is ae reason for recognition that it takes a long time for people to typically get into remission for substitute disorder. 45 years after the onset of a Substance Abuse disorder before people actually start seeking help. Takes it further roughly eight years on average to get one year of remission after people start seeking help. Roughly four to five treatment episodes in the clinical populations. Noteworthy, however, is even though it takes a long time to get that precious one year of remission, it takes forfive years of continuous more likely be no than anybody else in the general population to meet criteria for Substance Use disorder in the next year. In other words, it takes 45 years for remission to be no more likely to get below that 15 line. 15 is the annual rate in the general population and criteria for Substance Abuse disorder. It would be no more likely than anyone else in the criteria for Substance Use disorder in the following year if you have already had Substance Use disorder it takes 45 years. That does not suggest 30 days of rehab. Right . Is longtermsts treatment models and Recovery Support structures, like oxford aa, likelike longterm clinical recovery paradigms. By the way, all of what i have mentionedut, and paul this, the general surgeons report, i was lucky to be involved in that, honored to be one of the workers on that. It is downloadable for free. Its an easy to read document. I would encourage you to read it. 37 chapters, a lot of illustrations and their and even i can understand it. So what do we do in this National Recovery study . The reason we did this is because people like bill white have been talking about for decades, look, we have libraries on the causes of addiction, libraries full of books on all that. Weve got libraries on how to acutelye people, stabilize people, detoxify people. But how much do we know about the factors involved in remission and longterm recovery . Yet, there are millions, tens of millions, turns out, of people in recovery that we could actually do research and ask them what has helped you. What has made the difference . What are the things i have really helped . We conducted this National Recovery subject study. I spent weeks making them beautiful for you. [laughter] can have you what, you them. I will send them to you. You can post them. [applause] absolutely. We will post the slides and you can have them. I am happy to send any papers he want on the research. Happy to send those as well. One of the first papers we did from this study, which was one , wase reasons for doing it to estimate National Recovery. We had a National Representative sample, a sampling frame of 40,000 americans who were benchmarked to the u. S. Census. Them, did you use to have a problem with alcohol or drugs and no longer do . It abroad because we want people to self defined public resolution. I wanted to identify those who identify as being in recovery. We found 9. 1 of the u. S. Population has resolved significant drug or alcohol problem. Thats 22. 3 5 Million People. The significant drug or alcohol problem in the united states. 60 , up primary substance, the biggest one of those in recovery is alcohol. National survey of drug use and health came out this week for 2018, of all but 20 million to 20 million cases, 25 are alcohol. 25 are other drugs. All other drugs combined. A largeraw was portion, 60 , roughly, of those in recovery had their primary substance as alcohol. We had about 10 of cocaine. 10 of methamphetamine. 6 opioids, 13 cannabis. Also, onenteresting of the reasons i wanted to ask that question, did you once have a problem with drugs or alcohol but no longer do . I wanted to estimate the proportion of people who identify as being in recovery who adopt that label. Roughlyfound was that half of those who said that they resolve their significant drug or alcohol problem self identified as being in recovery, adopted that label. What were the predictors of adopting that label . As you might suspect, people whose lives have been more severely impacted by alcohol or other drugs were more likely to adopt that label. It may serve a self preservation, may be self preserving story and a sense that, if your life has been severely affected, you want to keep it right here because you dont want to get burned again. The impact that had on peoples lives signified that and did thatct the adoption of identity. For those whose lives were less severely affected by substances, they tended to be a mixture of people who decided not to identify with recovery, or they wanted to leave it in the past and not think about it or talk about it again. I want to say is about pathways. What did we find in terms of pathways of recovery. Was that, similar to many other studies that have been done, looking at different pathways, there are many pathways of recovery and all should be celebrated. There are clinical pathways, these are the more formal treatments of pathways that people follow. Thats one way people get into recovery. Another way is through nonclinical but service use pathways like using mutual aid groups like aa and smart recovery, etc. We callpathway is what self management or natural recovery. People who dont use any kind of assistance but still get into remission. What we found in this study, again, we had a broad base of people who self identified in a drug or alcohol problem. If the 4 used an assistant pathway. 46 did not. 54 used an assistant pathway, 46 did not. No help got them to resolve their problem. Again, when we look at the using thosef different pathways, as you might guess, the ones that were more severely impacted and affected by a addiction tended to use treatment and mutual help groups and medications. Those who are less severely affected were able to change without those kinds of external supports. Were usedvices that by people, the biggest one was mutual help groups like aa and na. About a quarter use formal treatment. 9 , medications. 20 other Recovery Support centers, including oxford house in Recovery Community centers. As a sidebar,ngs because we just finished a systematic review looking at the scientific literature on aa and 12 step that 12 step facilitation treatment. The cousin was the biggest piece of the pie in terms of how people recover, those who used there haservices, been a lot of misinformation and misconstrue of twelvestep facilitation and aa in the media. We are coming out with a systematic review, which will hopefully be published in the next couple of months, which is the Gold Standard of medical science. What we found in this particular review, 27 studies, very high quality of randomized controlled trials and five economic studies. Interestingly, 12step fertility shins facilitations compared to other therapy did as well, or slightly better than these more wellestablished treatments. Was int really stood out helping people achieve continuous abstinence and achieve remission. Twelvestep facilitation, on average, reduced about 50 more cases of complete abstinence over three years compared to well other established treatments. Will we looked, at the economic studies, there have been for five economic studies that were included in only didt, not twelvestep facilitation do better in terms of helping people maintain abstinence over but it did so at a substantially reduced health care cost. Pok. Peopletwoyear period, who are linked to aa and na, but about 10,000ed over two years in Health Care Costs. Relative to people who did not receive that linkage. And they had one third higher abstinence. Just taking that alone, translating that into all the people treated for alcohol use disorder, roughly one Million People per year, if they were all linked to aa, that would say 15 billion just in Health Care Costs and produce better outcomes. [applause] prof. Kelly now. Thats pretty impressive. Its kind of what we want from a Public Health standpoint. Free,have something ubiquitous, indigenous recovery resource in the committee in which in the community in which people live, that can mobilize therapeutic methods formalized by formal treatments, that is to say, helping people maintain motivation, helping selfefficacy, reduce efthicacy. It is the closest thing we have close to a freelance. There are millions of people who utilize these resources in the community. Supports thence notion that i think you all have known for a long time, and many people have known and the literature is now clarifying that when we actually link patients to these free ubiquitous Recovery Support resources, they do better and we save money. It has also been shown in the oxford house. You may have sn the study. Highquality randomized study. Randomizing them with a Substance Abuse disorder to go to an oxford house treatment versus to go home and receive outpatient treatment. The people went to the oxford house and did a study. Substantially better Substance Use outcomes. Absent over two years compared to 31 . [applause] rate kelly the employment over two years with 76 in the oxford house, 49 in usual care. [applause] and thelly reincarceration rate, criminal justice involvement was two thirds less in the oxford house compared to the usual. [applause] only forly so, not those clinical and Employment Outcomes better, criminal justice outcomes much better, but it also reduced cost of society of 30,000 per person over that twoyear period. [applause] again, this rise in the community, what we call Recovery Support services, oxford houses, sober living environments, Recovery Community centers, mutual aid groups, recovery high schools, recovery programs, all of these Recovery Support services that have grown and are now being evaluated are showing very good outcomes. It makes sense when we think about a chronic illness. If we were talking about an acute illness that could be solved within a 30 day period, then we would not need all of this. The reality is that people recognize what they need. Not available, they construct it. That is what has happened with oxford house. People recognize there was a need. It was not the government saying we needed it, it was the people suffering saying, we need more, we need something else. This is what has happened with mutual aid, oxford homes, collegiate recovery, all of these different paradigms, Community Centers which are growing. Gangbusters all over the country providing Recovery Support services, increasing Recovery Capital in the communities which people live in which people live. So, i will tell you in the time i got left, i think one of the things i am particularly interested in and focused on is that changes and what happens in recovery. 2000 people in the sample reported that they had a drug or alcohol problem. One of the things we were interested in was looking at with what happens to things like quality of life, selfesteem, happiness, distress and Recovery Capital when they get into recovery. Again, i cant see this fight, but i can describe it to you. I cannot see the slide, but i can describe it to you. It has to do with the positive entity of time. We we look over the 40 year pe with onehave people week in recovery to 40 years in recovery. We had 2000 people in the sample. What we saw was this steep increase in the first five years. Selfesteem, happiness, quality of life, Recovery Capital and a decrease in psychological distress. That is what you had hoped, that there are see, but some interesting nuances to that story. Inst of all, let me say that keeping with the point i made earlier remember i said it takes forfive years before you reach that stable point in remission we know more than anyone else out there and you are likely to meet criteria, this data shows the same thing. Its a steep climb in that first five years where people are really trying to get back their lives on track and build that recovery cap until you get that quality of life back. That is what is reflected here. We see an Inflection Point that happens roundabout. It starts to level off. , asgood news is is that people stay in recovery, it looks like a psychological distress decreases or people are better able to cope with psychological distress, and people continue to accrue Recovery Capital. , quality ofpier life improves and selfesteem in. What is interesting was that it took 15 years, however, before the sample reached the same quality of life as the general population. 15 years. To me, that is way too long. I think part of the problem here has been our cultural psyche about how we treat addiction. We tend to treat addiction my gay burning building. We recognize an emergency situation to put out the fire. Ist we failed to do recognize that we failed to put out the fire. What about providing the that thematerials person can use to rebuild that building or rebuild that life . What about most importantly, the Building Permit. So that building can be rebuilt. What happens with people with drug convictions is that they cannot get a loan, they cannot get housing, they cannot get a job because of prior criminal convictions. They cannot get the Building Permit to even rebuild their life. This is something that has stymied peoples efforts. It really diminishes hope that people can have a chance at a better life in recovery. One of the things that we that these changes in quality of life and Recovery Capital are not the same for all people. There are different people. Particularly those who had opioid and stimulant use disorders. Those using crack cocaine or methamphetamine, cocaine or opioids tend to have a tough time earlier on. They took about 23 years in terms of achieving the same level as Recovery Capital as those individuals who had other drug use disorders, alcohol or cannabis. The quality of life did not improve until two or three years into recovery. It did not get to the same level as those who had cannabis or alcohol use disorders. Is certainuggests individuals, perhaps more marginalized or stigmatized those ofls, such as opioid use disorder need more support, more Recovery Capital in order to achieve the same quality of life as others. We also found in this study that people with opioid use disorders and heroin histories have a harder time disclosing the fact that they are in recovery compared to people with other Substance Use disorders. Feeling ahey are deeper sense of stigma, discrimination and shame. This is pervasive across Substance Use disorders. This is tough to deal with for anybody because we are dealing with stigma and discrimination everyday. What we noticed in this study, have peopleto with open problems had a tougher time disclosing it to people. That means they dont get as much relief for help as others. We need to do more. Supervisors supervisees is studying and doing an intervention to talk about this. Closing, because im out slides. You have these i will be moderating the panel on research with a really stellar cast of players. Let me just sum up here. 9. 1 , 22. 3 5 million americans have drug or alcohol problems. Half of those self identify as being in recovery, have to not. Those who do tend to have more severe histories in terms of their addiction histories. Approximately half result in substance problems without any assistance. The quality of life indices, we look at quality of life in recovery, we see general steepses, particularly increases in positive indices in the first five years, which then become shallower. Some people have lower amounts of recovery, access to recovery resources, and its important to remember that people need those Building Materials and they need a Building Permit to be able to get started and give them hope. With that, i think i will leave you alone. I will see you later. In a few minutes. Thank you so much. [applause]