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 Medical Centers Palo Alto California Veterans Affairs and Stanford University Medical Centers, Palo Alto, California And Institute of Psychiatry and National Addiction Centre, King s College London

What is this thing called recovery (and why should addiction psychiatrists care)? A set of ideas and values A group of interventions A political l movement

Ideas and Values Treatment is a Good Thing, but Treatment is Not Recovery Optimism About People with Addictions Valuation of Experiential Knowledge Addiction is a Legitimate and Chronic Illness

Incorporating Recovery Principles into Treatment Increases Cost-Effectiveness Sample: 249 low-income alcohol-dependent patients Design: Random assignment to usual care or experimental unit with 50% less staff and higher expectation of patient self and mutual help Results: One-year outcomes comparable except for better social adjustment among experimental patients Source: Galanter, M. et al. (1987). Institutional self-help therapy for alcoholism: Clinical outcome. Alcoholism: Clinical & Experimental Resesarch, 11, 424-429.

Recovery as a Set of Interventions Peer-driven driven, experientially-informedinformed Can be paid or unpaid roles Include housing, mutual-help groups, schools, businesses, community centers and recovery coaching

Selected data on clinical and cost-effectiveness* *Summarizing the data where they are at present

Clinical trial of Oxford House Oxford House is a democratic, selfsupporting, peer-managed residential setting 150 Patients randomized after inpatient treatment to Oxford House or TAU 77% African American; 62% Female e Follow-ups every 6 months for 2 years, 90% of subjects re-contacted

At 24-months, Oxford House (OH) produced 1.5 to 2 times better outcomes 80 70 60 50 40 OH 30 TAU 20 10 0 Abstinent Employed Incarc Jason et al. (2006). Communal housing settings enhance substance abuse recovery. American J Public Health, 96, 1727-1729.

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 ih rates of f12-step involvement in intensive condition o 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, 678-688.

It Intreatment t tpreparation for AA produces better outcomes ON/OFF design with 508 patients Experimental received Making Alcoholics Anonymous Easier (MAAEZ) training i 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, 228-239.

Treatment programs that strongly promote recovery mutual help involvement have lower 1-Year Costs: Study of over 1,700 substance-dependent veterans. Humphreys, K., & Moos, R. H. (2001). Can encouraging substance abuse inpatients to participate in self-help groups reduce demand for health care?: A quasi-experimental study. Alcoholism: Clinical and Experimental Research, 25, 711-716.

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) Humphreys, K., & Moos, R. (2007). Two year clinical and cost offset outcomes of facilitating 12-step self-help group participation. Alcoholism: Clinical & Experimental Research, 31, 64-68.

How Could Addiction Psychiatrists and Other Health Professionals Maximize the Impact of Recovery-Oriented Interventions?

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, 371-376.

Peer-based 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

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 s 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.

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 groups Visi its to se elf-help 2250 2000 1750 1500 1250 Oakland (prior to intervention) Oakland (during intervention) Los Angeles (prior to intervention) Los Angeles (during intervention) 1000 1 2 3 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, 413-424.

Recovery as a Political Movement Emerged in the US Spread to Scotland, then rest of UK Character and Goals vary by country

Conclusions Many recovery ideas and values are already present in addiction psychiatry, though have potential for growth Some recovery oriented-interventions (12-step groups and doxford dh Houses) )have strong evidence of effectiveness and cost-effectiveness Most recovery-oriented interventions have not been evaluated Health professionals can maximize the impact of recovery-oriented interventions The recovery political movement is a rising force