Identifying Environmental Risk Factors for Relapse from Substance Use Disorders

Monica Rousseau, MPH University of South Florida Objectives • By the end of Part 1 of the presentation, attendees will be able to describe the gaps in current relapse prevention models • By the end of Part 2 of the presentation, attendees will be able to describe community-wide risk factors for relapse Objectives • By the end of Part 2 of the presentation, attendees will have a better understanding of and describe potential interventions to deploy in their local communities to reduce risk of relapse among people in recovery from substance use disorders. Outline • Part One: Background – Scope and Significance of Problem – Guiding Theories – Current Literature – Gaps in Practice, Theory, Literature • Part Two: Qualitative Study – Methods – Results – Implications

Scope of Problem Downstream Problem Scope of Problem Scope of the problem… – Drug overdose is now the leading cause of accidental death in the U.S (Rudd, 2016).

– Alcohol and drug use have been credited with an unprecedented decline in life (Case & Deaton, 2015).

– Opioid use alone costs the U.S. more than 500 billion dollars annually (CEA, 2017). Scope of Problem National, State, and Local Responses – It is a public health priority to identify and implement the most cost-effective and efficacious interventions to reduce addiction and its consequences Scope of Problem Areas of solutions – Primary Prevention • Increasing access to evidence-based curricula, campaigns, measures to decrease access – Secondary Prevention • Increasing SBIRT initiatives, care navigation, – Tertiary Prevention • Increasing medicine/medication assisted treatment (MAT) access, care coordination, RSS – MAT is the use of FDA-approved medications in combination with behavioral therapies to help patients manage and recover from their SUDs (Bonhomme et al., 2009). Scope of Problem Given that… – 12 month SUD relapse rates continue to exceed 60% (McLellan et al., 2000; Hendershot et al., 2011) – and only 35%- 54% of people with SUDs ever reach remission status (Fleury et al., 2016)

…it’s imperative to spend substantial attention on preventing relapse. Scope of Problem Given that… – Not all people will want to engage in MAT – MAT is not available for all SUDs, depending on the substance – SUDs are evolving, chronic diseases (HHS, 2015)

…we must have diverse interventions to prevent relapse. Relapse Research Definitions – Lapse is the initial return to the problematic behavior the individual is seeking to change (Hendershot et al., 2011).

– Relapse is a setback that occurs during the behavior change process in which the progress of the behavior change or maintenance is disrupted by a consistent reversion to the previous, problematic behavior (Hendershot et al., 2011).

There are two main models of Relapse – Cognitive Behavioral Model of Relapse (Marlatt and Gordon 1985) – Dynamic Model of Relapse (Witikietz and Marlatt 2004) Relapse Models Cognitive Behavioral Model of Relapse – Marlatt and Gordon 1985 – Based on cognitive-behavioral theories – Emphasizes contextual factors – Key components • Antecedent: an immediate, high risk situation • Self-efficacy: a sense of control • Abstinence Violation Effect: the loss of self- efficacy after breaking personal goals or rules. Relapse Research Cognitive Behavioral Model of Relapse Relapse Research Dynamic Model of Relapse – Witikietz and Marlatt 2004 – To better reflect the nonlinear process – Key components remain; new key components • Tonic processes: distal risks predispositions that raise a person’s risk for lapse or relapse – Ex: personality, genetics, family, relationships, etc. • Phasic responses: proximal factors that serve to prevent lapse or relapse. – Ex: cognitive processes such as cravings, moods, temporary changes in outcome expectancies, and the immediate effects of substance use Relapse Research Dynamic Model of Relapse Gaps in Theory • Many scholars believe there should be more emphasis outside of the intrapersonal determinants of relapse (Hendershot et al., 2011).

• Despite referencing social determinants and wide scale interventions, identified determinants mainly encompass intrapersonal and interpersonal determinants (Hsu & Marlatt, 2012). Literature Review • Socio-Ecological Model – Bronfenbrenner, 1979 – Behavioral change is influenced by altering risk and protective factors within several domains – Reciprocity – “Environmental Factors”

Image from localfood.ces.ncsu.edu/ Literature Review

• PRISMA- Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) • PubMed, Web of Science, Scopus, and PsycINFO for applicable studies • Keywords – SUDs, addiction, substance abuse, dependence, recovery, remission, recovery maintenance, abstinence, relapse, lapse, relapse prevention, risk factors, protective factors, predictors, relapse determinants, socio-ecological, environmental, social determinants of health, biopsychosocial • Exclusion Criteria – MAT – Anything before 2008 Literature Review

• Records Identified: 165 • Records Removed after Duplicates: 110 • Records Screened: 110 • Full-Text Articles Assessed: 26 • Studies Included in Final Synthesis: 16 Thematic Analysis

2 Number Articles of Number

SEM Domains Gaps in Literature • Only two studies had data which spanned all domains of the socio-ecological model • Only three studies concluded that policy level factors influenced relapse and listed specific policies. – lack of funding for housing (Manuel et al., 2017) – restrictive Chinese ID card laws for people (Yang et al., 2015) – state regulations ensuring sobriety (Wright et al., 2014) Gaps in Literature • Observations from Literature Review – Need for diverse research methods • Only 2 were qualitative, published studies – Need to research risks at different levels of recovery • Most articles focused on short-term recovery – Need for more research on the topic – Need for more research conducted in the United States. Gaps in Literature • Need for more research on the topic – Only 16 studies were identified for full review. • Of these 16, only 11 included environmental factors related to relapse • Of those 11, only 5 studied populations in the United States • Of those 5, only 3 were published.

Significance of Study • It is of paramount importance to begin focusing attention on successfully intervening and preventing relapse. • In order to do so, we must first better understand the environmental risk factors that influence relapse. Scope of Problem Given that… – 12 month SUD relapse rates continue to exceed 60% (McLellan et al., 2000; Hendershot et al., 2011) – and only 35%- 54% of people with SUDs ever reach remission status (Fleury et al., 2016)

…we must have diverse interventions to prevent relapse. Purpose The purpose of this study was to identify the environmental risk factors for substance use disorder relapse in Pasco County, Florida.

Image from localfood.ces.ncsu.edu/ Study Question What are the environmental risk factors related to relapse among Pasco County residents living in recovery from substance use disorders?

Image from FDOT.gov Scope of Problem • Local Problem – 46,000+ people with a Substance Use Disorder (SAMHSA, 2017) – SUDs linked with top causes of deaths (Florida Charts, 2018) –5th highest drug overdose mortality rate out of 67 counties (County Health Rankings, 2017) Study Methods • Exploratory, qualitative study – Institutional Review Board exempt – Identify the environmental risk factors for relapse • Policy Risk Factors • Community Risk Factors • Organizational Risk Factors – Recorded, semi-structured interviews Study Methods • Exploratory, qualitative study – Open ended questions • Personal experiences • Most significant roadblocks in personal life • Most significant roadblocks to people living in recovery in Pasco County • Emotions they felt prior to lapse – 30-60 minutes per interview Study Methods

• Purposive Sample – Must have lapsed at least once – Must have been in recovery for more than one year – Must live, or lived, in Pasco County, Florida for more than one year of time while in recovery – Recovery status and the lapses must NOT include MAT medications (ex: buprenorphine) Study Methods Recruitment – People in recovery and peer support specialists helped recruit study participants in recovery – The PI met with individuals who expressed interest in the study • Explained the purpose of the study • Obtained written consent to participate in a recorded interview. Study Methods • Participant Characteristics – N=17 – 10 women; 7 men – Ages 25-60 – Number of lapses ranged 1- 40 • Median: 3 Study Methods • Participant Characteristics – All poly-substance use – 12 stated an opioid as drug of choice – 13 people with a drug of choice that doesn’t have MAT – 10 had a lapse after 1 year of abstinence – 13 had a lapse within one year of abstinence Study Methods Data Analysis – Transcribed all text – Framework Analysis • Socio Ecological Model • Theory at a Glance • Split responses according to length of time in recovery – MAX.QDA Software Results: Environmental Roadblocks

Domain/Theme # Coded # of Segments Participants Public Policy/ Law 37 6 Roadblocks Community 90 17 Roadblocks Organizational 34 12 Roadblocks Results- Environmental Roadblocks

Domain/Theme # Coded # of Segments Participants Public Policy/ 37 6 Law Roadblocks Community 90 17 Roadblocks Organizational 34 12 Roadblocks Results- Policy Roadblocks

Code # Coded # of Segments Participants Industry Regulation 2 1 Health Insurance 3 3 Felony Charges 32 4 • Jobs • Housing • Driver’s License • Higher Ed • Paying Court Costs Results- Policy Roadblocks

“…I can't get out of hospitality and I'm struggling to get my license back, and no one will give me a home to live in.... So I have to live with my parents. It's just it was just literally like a cumulative of those things. And prior to relapse that that was just like you know what. ‘Maybe a drink will make everything better’.” Results- Community Roadblocks

Domain/Theme # Coded # of Segments Participants Public Policy/ Law 37 6 Roadblocks Community 90 17 Roadblocks Organizational 34 12 Roadblocks Results- Community Roadblocks

Code # Coded # of Segments Participants Easy Access to Drugs 28 14 Drug Use Culture 7 3 Stigma 11 7 Lack of Accessible 44 13 Resources • Employers, Public Transportation • Tx After-care • Housing • 12-Step Results- Community Roadblocks “I thought that I would relapse on alcohol faster because it's more readily available and I drank every single day…And like, I was in an apartment complex where I mean one of my relapses, I found a pill on the washer of the laundry in the laundry room. Like who finds a pill and then just takes it off of the laundry? But who leaves it? But so that's what I was surrounded by.” Results: Organizational Roadblocks

Domain/Theme # Coded # of Segments Participants Public Policy/ Law 37 6 Roadblocks Community 90 17 Roadblocks Organizational 34 12 Roadblocks Results- Organizational Roadblocks

Code # Coded # of Segments Participants Probation 15 5 RSS Providers 2 2 Stigma 11 7 Workplaces 44 13 • Hiring Procedures • Culture • Scheduling Results- Organizational Roadblocks

• “But I also kept working alongside people that were using and drinking…I was a server. Back then I was a server. Now I actually have a real- or not that that's not a real job- but I was a server so I was surrounded by it.” – Example of organizational culture roadblock Results- Organizational Roadblocks

• I definitely also, specifically after hearing about multiple pathways and talking that through, I think a lot of the 12 step programs are definitely...they're kind of clicky so they're like be in here or don't be in here - you know. Results: Environmental Factors Results: Most Significant Barriers- Pasco vs Personal Domains of Roadblocks Most Sig. Most Sig. Pasco Personal Results

Domain/Theme Lapse after Lapse within 1 Year 1 Year

Results Conclusions - Environmental Roadblocks: - 10 broad roadblocks were identified - Community Domain had the most roadblocks - Issues finding housing, jobs, and 12-step fellowships were most commonly referenced and pressing issues for people living in recovery in Pasco - Probation was a leading issue for people with felonies Conclusions • People who lapse after 1 year have different experiences than those who lapse within 1 year - Struggle understanding illness vs struggle stabilizing and integrating in the community - Emotions of people just before lapse - A burden of shame Strengths and Limitations of Study Strengths – Innovative design – Hard to reach population – Ability to influence local conditions and shape community investments

Limitations – Not generalizable results – Researcher Bias – Abstinence-based group; 12-Step centered Implications • Implications for Population – Majority of participants used multiple substances – 13 participants with a drug of choice that doesn’t have MAT – Emphasizes the concept that we must have diverse interventions to prevent relapse. – Results inform potential interventions that would benefit underserved populations Implications • Implications for Prevention/Public Health – Better help PH professionals create health in all policies • Health in All Policies= #HiAP • Opportunities to highlight the health repercussions of policies related to violating parole, revoking licenses, health care expansion etc. • Opportunities to influence such policies – Stigma Campaigns • Opportunities for targeted to be within Recovery Community Implications • Implications for Prevention/Public Health – Working with organizations to increase access to 12 step fellowships/ mutual aid support groups • Employers who hire people with felonies could be encouraged to promote nearby/co-located support groups – Transportation – Informing institutional opportunities for improvement • probation Implications • Implications for Behavioral Health – Could help expand upon theoretical models of relapse • Informs and elaborates upon antecedents and tonic processes – Could influence discharge planning, continuity of care/aftercare • Leveraging the knowledge of peers about local support group culture Implications • Implications for Behavioral Health – Inform ROSC – Help inform long-term strategies to keep people engaged with providers • 6-month mark; 12-month mark, etc. – Inform incidental funding • Social skills, life skills, finding a “home” 12-step Departing Thoughts

• We can continue to offer treatment, but until we better understand and fix the reasons our neighbors keep falling back into the river, we will not be fully successful • We must address all factors within SEM – Intrapersonal, interpersonal, organizational, community, and policy • Next steps: Design interventions. Deploy. Evaluate. Questions? References

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