Keith Humphreys. Circles of Recovery: Mutual help Organizations for Substance Use Disorders

Size: px

Start display at page:

Download "Keith Humphreys. Circles of Recovery: Mutual help Organizations for Substance Use Disorders"

Adele Goodwin
8 years ago
Views:

1 Circles of Recovery: Mutual help Organizations for Substance Use Disorders 31 March 2015 School of Social Service Administration University of Chicago Keith Humphreys Professor of Psychiatry, Stanford University Career Research Scientist, U.S. Veterans Health Administration

University of Chicago Keith Humphreys Professor of Psychiatry,

2 Overview Definition and Scope of mutual help organizations Effectiveness and Cost-effectiveness of 12-step based groups Clinical and Policy implications

3 Definition of Self-Help (aka Mutual Help) Organizations Essential Peer-directed, self-governing Value experiential knowledge and reciprocal helping Free or nominal cost only Some Provide a structured program and philosophy Have an abstinence orientation Attendance by addicted person/attendance alone Spiritual or Religious Content Have a Residential Structure

only Some Provide a structured program and philosophy Have an abstinence orientation

4 Addiction self-help organizations are an international phenomenon Austria: Blue Cross France: Vie Libre Hong Kong: SAARDA Japan: Danshukai Poland: Abstainer s Clubs Sweden: The Links Iran: Narcotics Anonymous

5 Lifetime and past 12 months participation in self-help groups, Substance Problems Eating Problems Note: Based on MIDUS survey (N=3032) Emotional Crisis Physical Illness/Disease Family Other Any Past 12 mos. Lifetime Source: Kessler, R.C. et al., 1997, Patterns and correlates of self-help group membership in the United States. Social Policy, 27,

Physical Illness/Disease Family Other Any Past 12 mos. Lifetime Source: Kessler, R.C. et al.

6 Help-seeking visits in U.S. for psychiatric and substance abuse problems by sector 40.1% Self-help 8.1% General Medical Human Services 16.5% Mental Health Specialty Source: Kessler, R.C. et al. (1997). Differences in the use if psychiatric outpatient services between the U.S. and Ontario. NEJM %

7 But do they work? Popularity does not equal effectiveness However, a sizable evidence base has accumulated regarding 12-step oriented interventions

8 Background on AA, the prototypic 12-step organization Founded in Akron, Ohio in 1934 Sole purpose: To help alcoholics become sober Explosive growth in U.S. and world Non-diverse to start, now wildly so 4-6 million members worldwide Spawned many spinoffs and also influence professionals substantially

9 Veterans Affairs RCT on AA/NA referral for outpatients 345 VA outpatients randomized to standard or intensive 12-step group referral 81.4% FU at 6 months Higher rates of 12-step involvement in intensive condition Over 60% greater improvement in ASI alcohol and drug composite scores in intensive referral condition Source: Timko, C. (2006). Intensive referral to 12-step self-help groups and 6-month substance use disorder outcomes. Addiction, 101,

4% FU at 6 months Higher rates of 12-step involvement in intensive condition Over 60% greater improvement in ASI

10 Changing network support for drinking trial (n= 210) Patients Randomized to Case Management or Network Support Approaches At 15 months, network approaches had higher AA involvement, 20% more abstaining days Mark D. Litt, Ronald M. Kadden, Elise Kabela-Cormier, and Nancy Petry (2007). Changing Network Support for Drinking: Initial Findings From the Network Support Project. Journal of Consulting and Clinical Psychology, 71,

D. Litt, Ronald M. Kadden, Elise Kabela-Cormier, and Nancy Petry (2007).

11 Integration of federally funded 12-step facilitation trials Instrumental variables analysis of over 2,300 patients in six trials Used randomization as instrument to test impact of AA free of selection bias AA effective in 5 of 6 trials Alcoholism Clinical and Experimental Research, 38 (on line early)

as instrument to test impact of AA free of selection bias AA effective in 5

12 Clinical trial of Oxford House Oxford House is a 12-step influenced, peermanaged residential setting in which almost all patients attend AA/NA 150 Patients randomized after inpatient treatment to Oxford House or TAU 77% African American; 62% Female Follow-ups every 6 months for 2 years, 90% of subjects re-contacted

Patients randomized after inpatient treatment to Oxford House or TAU 77%

13 At 24-months, Oxford House (OH) produced 1.5 to 2 times better outcomes OH TAU Abstinent Employed Incarc Jason et al. (2006). Communal housing settings enhance substance abuse recovery. American J Public Health, 96,

14 Replication of cost offset findings in Department of Veterans Affairs Sample Source: This study appeared in Alcoholism: Clinical and Experimental Research, 25,

15 Quasi-Experimental Design, I Follow-up study of over 1700 VA patients (100% male, 46% African-American) receiving one of two types of care: 5 programs were based on 12-step principles and placed heavy emphasis on self-help activities 5 programs were based on cognitivebehavioral principles and placed little emphasis on self-help activities

12-step principles and placed heavy emphasis on self-help activities 5 programs were

16 Quasi-Experimental Design, II Nearest programs hundreds of miles apart Patients matched on prior mental health/ SUD care utilization No baseline differences in marriage, employment, comorbid psychiatric disorder, current substance use, service utilization or self-help group involvement 100% follow-up on utilization outcomes, 84% on other outcomes

marriage, employment, comorbid psychiatric disorder, current substance use, service

17 Self-help group participation at 1- year follow-up was higher after selfhelp oriented treatment 36% of 12-step program patients had a sponsor, over double the rate of cognitive-behavioral program patients 60% of 12-step program patients were attending self-help groups, compared with slightly less than half of cognitive-behavioral program patients

cognitive-behavioral program patients 60% of 12-step program patients were attending

18 1-Year Clinical Outcomes (%) Abstinent No SA Prob Pos MH 12-step Cog-Beh Note: Abstinence higher in 12-step, p<.001

19 1-Year Treatment Costs, Inpatient Days and Outpatient visits $1000 cost IP Days Cog-Beh 12-step OP Visits Note: All differences significant at p <.001

Cog-Beh 12-step OP Visits 0 5 10 15 20 25

20 2-year follow-up of same sample 50% to 100% higher self-help group involvement measures favoring 12-step Abstinence difference increased: 49.5% in 12-step versus 37.0% in CB A further $2,440 health care cost reduction (total for two years = $8,175 in 2006USD)

difference increased: 49.5% in 12-step versus 37.

21 What mediates these benefits?

22 B mediates the relationship between A and C A>>>>>>>>>à B>>>>>>>>à C

23 Structural equation modeling results from over 2,000 patients assessed at intake, 1-year, 2-year Active Coping Self-Help Group Involvement Motivation to change General Friendship Quality Reduced Substance Use Friends Support For Abstinence Note All paths significant at p<.05. Goodness of Fit Index =.950, Annals of Behavioral Medicine, 21: 54-60

24 Partial mediators of 12-step groups effect on substance use identified in research Increased self-efficacy Strengthened commitment to abstinence More active coping Enhanced social support Greater spiritual and altruistic behavior Replacement of substance-using friends with abstinent friends

25 12-step vs. non-12 step based friendship networks of 1,932 treated SUD patients %friends in 12S %Abstainers 12-step Non Source: Humphreys, K., & Noke, J. (1997). The influence of posttreatment mutual help group participation on the friendship networks of substance abuse patients. American J of Community Psychology, 25, 1-16.

26 Clinical and Policy Implications

27 Intreatment preparation for AA produces better outcomes ON/OFF design with 508 patients Experimental received Making Alcoholics Anonymous Easier (MAAEZ) training At 12 months, 1.85 higher odds for alcohol abstinence, 2.21 for drug abstinence for those receiving MAAEZ Source: Kaskutas, L.A., et al. (2009). Journal of Substance Abuse Treatment, 37,

28 We do that already: Normal referral processes are ineffective Sample: 20 alcohol outpatients Design: Outpatients randomly assigned to standard 12-step self-help group referral (list of meetings and therapist encouragement to attend) or intensive referral (in-session phone call to active 12-step group member) Results: Attendance rate after intensive referral: 100% Attendance rate after standard referral: 0% Source: Sisson, P.W., & Mallams, J.H. (1981). The use of systematic encouragement and community access procedures to increase attendance at AA meetings. Am J Drug Alc Abuse, 8,

29 Self-help referral can be beneficial in non-specialty settings Control BI BI+Peer 6-month abstinence 36% 51% 64% TX/AA Initiation 9% 15% 49% Source: Study by Rick Blondell, M.D. of 140 patients hospitalized For alcohol-related injuries, J Fam Practice, 50

30 UK SMART expansion project Partnership between DoH, Alcohol Concern and SMART Recovery UK Developed training, local champions, referral processes in 6 sites in England Established 18 groups in 4 regions (12 original, 6 spinoffs) Raised profile of SMART with professionals and public Source: Macgregor, S., & Herring, R. (2010). The Alcohol Concern SMART Recovery pilot project final evaluation report. Middlesex University.

31 Visits to self-help groups in Oakland and Los Angeles in 3 months of Pro-Self-Help Media vs. in same 3 months of prior year 2500 Visits to self-help groups Oakland (prior to intervention) Oakland (during intervention) Los Angeles (prior to intervention) Los Angeles (during intervention) Humphreys, K., Macus, S., Stewart, E., & Oliva, E. (2004). Expanding self-help group participation in culturally diverse urban areas: Media approaches to leveraging referent power. Journal of Community Psychology, 32,

35 Conclusions 12-step group participation significantly reduces substance use and health care costs. Benefits of 12-step groups mediated both by psychological and social changes. Applying these findings in treatment settings should improve outcomes and reduce costs. Investment in self-help supportive infrastructure may benefit public. Recovery movement has political potential.

36 Thank you for your attention!

Mutual help, recovery and addiction: A research and policy perspective

Mutual help, recovery and addiction: A research and policy perspective Presented 4 May 2012 to UK RCP Faculty of Addictions Cardiff, Wales Professor Keith Humphreys Veterans Affairs and Stanford University