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Circles of Recovery: Mutual help Organizations for Substance Use Disorders 31 March 2015 School 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

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

Definition of Self-Help (aka Mutual Help) Organizations Essential • Peer-directed, self-governing • Value experiential 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

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

Lifetime and past 12 months participation in self-help groups, 1995 Lifetime and past 12 months participation in self-help groups, 1995

Help-seeking visits in U. S. for psychiatric and substance abuse problems by sector Help-seeking visits in U. S. for psychiatric and substance abuse problems by sector

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

Background on AA, the prototypic 12 -step organization • • • Founded in Akron, 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

Veterans Affairs RCT on AA/NA referral for outpatients • 345 VA outpatients randomized to 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, 678 -688.

Changing network support for drinking trial (n= 210) • Patients Randomized to Case Management 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, 118 -128.

Integration of federally funded 12 -step facilitation trials • Instrumental variables analysis of over 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)

Clinical trial of Oxford House • Oxford House is a 12 -step influenced, peermanaged 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

At 24 -months, Oxford House (OH) produced 1. 5 to 2 times better outcomes At 24 -months, Oxford House (OH) produced 1. 5 to 2 times better outcomes Jason et al. (2006). Communal housing settings enhance substance abuse recovery. American J Public Health, 96, 1727 -1729.

Replication of cost offset findings in Department of Veterans Affairs Sample Source: This study Replication of cost offset findings in Department of Veterans Affairs Sample Source: This study appeared in Alcoholism: Clinical and Experimental Research, 25, 711 -716.

Quasi-Experimental Design, I • Follow-up study of over 1700 VA patients (100% male, 46% 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

Quasi-Experimental Design, II • Nearest programs hundreds of miles apart • Patients matched on 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

Self-help group participation at 1 year follow-up was higher after selfhelp oriented treatment • 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

1 -Year Clinical Outcomes (%) Note: Abstinence higher in 12 -step, p<. 001 1 -Year Clinical Outcomes (%) Note: Abstinence higher in 12 -step, p<. 001

1 -Year Treatment Costs, Inpatient Days and Outpatient visits Note: All differences significant at 1 -Year Treatment Costs, Inpatient Days and Outpatient visits Note: All differences significant at p <. 001

2 -year follow-up of same sample • 50% to 100% higher self-help group involvement 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 2006 USD)

What mediates these benefits? What mediates these benefits?

B “mediates” the relationship between A and C A>>>>> B>>>> C B “mediates” the relationship between A and C A>>>>> B>>>> C

Structural equation modeling results from over 2, 000 patients assessed at intake, 1 -year, 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

Partial mediators of 12 -step groups’ effect on substance use identified in research • 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

12 -step vs. non-12 step based friendship networks of 1, 932 treated SUD patients 12 -step vs. non-12 step based friendship networks of 1, 932 treated SUD patients 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.

Clinical and Policy Implications Clinical and Policy Implications

Intreatment preparation for AA produces better outcomes • ON/OFF design with 508 patients • 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, 228 -239.

“We do that already: Normal referral processes are ineffective Sample: 20 alcohol outpatients Design: “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.

Self-help referral can be beneficial in non-specialty settings Control BI BI+Peer 6 -month abstinence 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

UK SMART expansion project • Partnership between Do. H, Alcohol Concern and SMART Recovery UK SMART expansion project • Partnership between Do. H, 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.

Visits to self-help groups in Oakland Los Angeles in 3 months of Pro-Self-Help Media Visits to self-help groups in Oakland Los Angeles in 3 months of Pro-Self-Help Media vs. in same 3 months of prior year 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.

Conclusions • 12 -step group participation significantly reduces substance use and health care costs. 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.

Thank you for your attention! Thank you for your attention!