Ago, which specifically mentions oxford house as a good thing and as a way for the future. With that, i call on john kelly to come share with us his knowledge so we can learn more about the disease we have in the road to recovery. [applause] this modern technology stuff jackson is good at adapting. [cheers and applause] we now have coasttocoast operation. Ricky is in the state of washington. [cheers and applause] speaker from massachusetts. We love you, ricky. [laughing] dont make ricky nervous. [inaudible conversations] [inaudible conversations] just to show you how we rebound, here we are. [applause] thank you. Good morning, everybody. Good morning. Delighted to be here. Im one of those phd some new england. I apologize upfront. But im so dependent on powerpoint. I cant speak, i cant even talk without powerpoint. [inaudible conversations] [inaudible conversations] [inaudible conversations] [applause] all right. Lets start over. Im delighted to be here with you all. I was getting worried. I was at, they invited me to come and speak at the call is anonymous World Convention in atlanta a few years ago, and they asked a a couple scientis, speak that research. Ive done research. They said dont bring slides. Dont bring slides to talk. So i was saying to the audience then, i said im so dependent on powerpoint and have to rely on my higher power point to do this talk. I was getting worried there i would have to do the same thing, but anyway, ive got some power now to my powerpoint slide. No, but im really honored, paul, thank you and the committee for inviting me to be with you all. I hope that what a courtesy is the least interesting if not informative and even helpful this morning. So thank you for inviting me. Thank you for having. I hope you have a great conference. [applause] so i think i have to do both of these things. I have to remember, remind me to click these okay, yeah. Looks different on there than here. But anyway, well get through it. If not, ill just tell a couple of jokes. Ive got some good ones. But so what i thought i would do this morning is to talk about longterm recovery, talk about recovery, a National Recovery study that we completed recently, talk about some of the findings from that study. And, what also want to do some context on how we came to this focus on remission and longterm recovery in terms of research. So im going to talk about kind of how we got here in the last 50 years. Ill talk about National Recovery study, and then when we did the National Recovery study ill talk about the prevalence of alcohol and drug problem resolution in the United States. Ill talk about what proportion of those individuals who have resolved a significant drug or alkyl problem identified being in recovery, the predictors of recovering person, what the pathways are that people follow in recovery to achieve recovery. Ill talk about what weve done to estimate the number of recovery attempts it takes before people achieve longterm recovery, stable recovery. And then ill talk about the functioning of people in recovery in the United States, and what happens over time and see if we can identify any milestones of recovery. Okay, that looks like a different slide there. Thats a different slide there. Unfortunately. Thats the wrong slide. Its different than the one on here. Thats the wrong one. All right. Given the time, time scenario here, i i might just have to tk it through. You might just see the slides, unfortunately. [applause] its all right. Im happy im feeling happy. [laughing] im still feeling happy and healthy and terrific. All right. Well, what i can see here, maybe you can gather around here. [laughing] you can see what im seeing, but so what i was going to tell you is this, okay, ive been reflective because its almost 50 years since the declaration of the war on drugs happen in 1970 under nixon. The very nature of that rhetoric implies what . It implies a militaristic identifiable target that we can defeat. As it turns out, although that was the initial stance, to be tough on drugs and tough on crime, weve moved from at that in the last 50 years from a broader approach to quote, unquote, the drug problem. If you look at the laws that have been passed in the last 50 years from the controlled substances act in 1970s to the drug abuse october of 1986, these laws were harsh rhetoric laws designed to be tough on crime, tough on drugs. The results of that, of course, was what . It was actually an increase in the prison population and worked in terms of locking people up. We have about 4. 1 of the worlds population and 25 of the worlds prisoners in the United States. Now, you could say, you could argue and say, yes, but it won the war on drugs. No, unfortunately, it did not. That recognition of the failure 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 on interdiction and supply, was also focusing on demand reduction, demand reduction, recovery. Think of the laws passed in the past 20 years, at Affordable Care act substituted as an essential health benefit, you had to be covered by insurance, exchanges in insurance company, that was a big shift. The comprehensive addiction and recovery act, or cara had been passed. And again, the idea is to focus not just on supply reduction, but also on demand reduction. I had the privilege and honor of being invited to the First Ever National drug policy reform summit held at the white house on december 9th, 2013. And that was under the director of omdcp at the time. And 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 kwon from the war on drugs to the war on the war on drugs. But we should also remember that the war on drugs declared in the 1970s also marked the concerted National Effort in terms of forging new ground in terms of treatment and prevention and recovery. And antiabuse of alcoholism and drug abuse 1974. 1972 samsa was founded, as a result, the last 50 years weve learn a lot of addiction and genetics and genomics and just like now, like other complex illnesses and disorders, Substance Abuse disorder is genetic disorder. Thats very clear, thats resulted from the research and funding supporting that research. We also, in terms of cause and controllability, these two factors associated with stigma and discrimination, so pervasive in addiction. We understand from the neuroscien neuroscience findings particularly the last 30 years through brain imaging and neuroscience, and the regulated control for using substances, despite the consequences, the essential feature is theability to regulate those impulses have opinion through our research on neuroscience. We can see much more clearly what happens in the brain in the subcortical areas as well as the cortical areas of the brain. How those are radically impaired as a function of chronic exposure to substances. Weve also had, think about, again, just think about 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, pre contemplation, contemplation, decision or preparation, action and maintenance. And then treatments designed to address the notion of ambivalence. This notion of ambivalence, kind of i do and i dont. Its greats im a clinician and its great when people come in and say tell me what to do and im ready to do it. Those are wonderful cases. But most people, 70 of people are coming in because of the police, their spouse, families, schools, i kind of wanted im here, but i dont want to be here, yes, i do, but i dont. What did we use today say . Go back and come back when youre ready. You could be dead by then. So bill miller and kind of the motivational interviewing paradigm which started in the early 90s, it was important because it said look as clinicians we cant just say go back and come back later. If ambivalence is a cardinal feature of addiction, we need to help patients, help them resolve at that ambivalence. So it made it a clinician problem. How do we as clinicians then do Something Different . To really listen, you know, its a good addage on the slide. What people really need is a good listening to, not a good talking to. We used to think a good talking to. But the paradigm what people need is a good listening to. Lets see the world through an accurate empathy and kind of see the world through their eyes. Weve had contingency management, good medications with people with alcohol and ipo use disord opioid use disorder. And what i want to focus on is longterm recovery thats taken shape. The reason why theres been a focus. Weve talked about addiction as a chronic illness for a long time, but have not treated it as such. Weve tended to treat it as a chronic as an acute illness. People like tom mcclellen, chuck obrien, william white, who have had the privilege of working with and publishing several papers and a book on Addiction Recovery management with and bill was really the guy, as some of you know, bill white, he was really kind of the architect of the chronic disease management or chronic Recovery Management paradigm. He provided a lot of the terminology and conceptualization how we address addiction as a chronic illness. And part of the reason for that is the recognition that it takes a long time for people typically to get into remission after they meet criteria for Substance Abuse disorder. It takes about four to five years after the onset of a Substance Abuse disorder before people actually start seeking help. Take the further roughly eight years on average to get one year permission after people start seeking help and roughly four to five treatment episodes in the most severe cases in the clinical population. Whats also noteworthy, however, is even though it takes a long time to get that precious one year of remission, it takes four to five years of continuous remission to be no more likely than anybody else in the general population to meet criteria for Substance Abuse disorder in the next year. In other words, it takes four to five years of continuoouous remission to get below the 15 line. 15 is the annual rate for getting to Substance Abuse disorder. And meeting criteria for Substance Abuse tornado. If youve already had Substance Abuse in order it takes four to five years. What does that suggest, it does in the suggest 30 years of rehab and by graduation. What it suggests is longterm treatment models and Recovery Support structures like houses, like aa, like other mutual help groups. Like longterm clinical Recovery Management paradigms. By the way, all of what ive talked about and paul mentioned this, the Surgeon Generals report i was lucky to be involved in that, honored to be one of the authors on that. Its down loadable for free. Its an easy to read document. Id encourage you to read it, only seven chapters and its got illustrations in there and even i can understand it. The what do we do in this National Recovery study . The reason why we did this is because people like bill white have been talking about for decades, look, weve got libraries on the etiology, libraries full of books like that, libraries how to stabilize people, acutely destabilize people and how much do we know in longterm recovery . Yet, there are millions, tens of millions, it turns out, of people in recovery that we could actually do research on, ask them what helped you . Whats made the difference . What are the things that have done that really, really help . So we conducted this National Recovery study, im sorry you cant see these slides. I spent weeks making them beautiful for you. [laughter] but i tell you what, you can have them. Okay . Ill send them to you. You can yes, you can post them. [applaus [applause] absolutely, well post the slides and you can have them anyway and im happy to send any papers you want on the research, happy to send those as well. So one of the first papers we did from this study, which was one of the reasons for doing it, was to estimate National Recovery, so we had a nationally representative sample, ruffling a sampling of americans who were bench marked through the census and the national representative. And asked them did you used to have a problem with alcohol or drugs and no longer do . We kept it broad like that because we wanted people to selfdefine problem resolution and there was a reason for that because we want today identify also those who identified being in recovery. And what we found was that 9. 1 of the u. S. Population resolved a figure drug or alcohol problem. 23. 25 Million People who have resolved significant drug or alcohol problem in the United States. About 60 , when we look at primary substance, as you might guess, the biggest one, the primary substance of those in recovery is alcohol. And the National Survey of drug use and health just came out this week, 2018, and it was over 20 million cases of Substance Abuse disorder in the United States, 75 of all Substance Abuse cases are alcohol. 20 are other drugs, all other drugs combined. So what we saw was a larger portion, 60 roughly of those in recovery were had their primary substance as alcohol. We had about 10 of cocaine, about 10 methamphetamine, 6 o opioids, 13 cannibus. One of the reasons i wanted to ask that question, did you once have a problem with drugs or alcohol and no longer do . I wanted to estimate the proportion of people actually being in recovery who actually adopted that label and what we found was that roughly half of those who said theyd resolved a significant drug or alcohol problem selfidentified as being in recovery, of adopting that label. What were the results of adopting that label, people whose lives had been more severely impacted by alcohol or drugs were more likely to adopt that label. So, it may serve a selfpreservation, maybe selfpre sserv selfpreservetory, you may keep it here because you dont want to get burned again. The significance to their lives with that identity. Those whose lives severely affected by substances, they were a mixture of people who didnt want to identify with the notion of recovery, they just wanted to leave it in the past and not think about it or not talk about it again. The next thing i want to say is about path ways. What did we find in terms of pathways of recovery . What we found similar to many other studies we have done, looking at pathways to recovery. There are many path ways and all should be celebrated. There are Clinical Pathways and these are more formal treatment and another way is through nonclinical, but service use pathways, aa, na, smart recovery and so on. The third pathway is selfmanagement and people who dont use assistance, but still get into remission. What we found in this study, again, we had a broad base of people who selfidentified as a result of a significant drug or alcohol problem. 54 used an assisted pathway and 46 did not. 46 didnt use any kind of service whatsoever. No treatment, no mutual help, but got in to resolve their problem. And again, when we looked at the predictors of using those different pathways,s a you might guess, the ones that were more severely impacted and affected by addiction tended to use treatment and mutual help groups, and medication. Those who were less severely affected were able to change without those kind of external supports. Of the services that were used by people, the biggest one was mutual help groups like aa and na. About a quarter you had used formal treatment. About 9 medications and other oxford houses and other centers. As a side bar because we just finished a review looking at literature on aa and 12step treatments, because that was the biggest piece of the pie in terms of how people recovered, those who used external services and ill tell you a little about that because theres been a lot of misinformation and misconstrual regarding 12step in media and the press. Were coming out with a systemic review we hope will be published in the next couple of months through the cochran system, the Gold Standard for medical science. What we found in this particular review, 27 studies, very high quality, rigorous, wellcontrolled studies, that interesting 12step facilitation treatment compared to cognitive and motivating did well or slightly better than the more wellestablished treatments. Where it really stood out though was in helping people achieve continue abstinence and achieve remission. 12step facilitation on average, produced about 50 more cases of complete abstinence over three years compared to other wellestablished treatments like cbt and met. Now, the other thing when we looked at the economic studies, there have been four, five economic studies that we included, were included in the report, not only did 12step facilitation actually do better in terms of helping people maintain abstinence over time and remission over time, but it did so at a substantially reduced health care cost, okay . It turns out, over a twoyear period, people who were linked clinically by clinicians to aa and na, but mostly aa, saved about 10,000 over two years in Health Care Costs relative to people who did not receive a linkage and they had one third higher abstinence rate. Now, just taking that alone, translating that into all the people who treated for alcohol use disorder in the United States, roughly one Million People per year, if they were all linked to aa, that would save 15 billion just in Health Care Costs and pr