The Evidence Base on Peer Managed Addiction Recovery

The Evidence Base on Peer. Managed Addiction Recovery Organisations Presented 8 June 2012 at NTA Conference, Birmingham, UK Professor Keith Humphreys Veterans Affairs and Stanford University Medical Centers, Palo Alto, California And Institute of Psychiatry and National Addiction Centre, King’s College London

Overview • Definition and Scope of peer-led recovery organisations • Effectiveness and Cost-effectiveness of 12 -step based organisations • Clinical and Policy implications

Definition of Self-Help (aka Mutual Help) Recovery Organisations 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: Poland: Sweden: Iran: Blue Cross Vie Libre SAARDA Danshukai Abstainer’s Clubs The Links Narcotics Anonymous

12 -step groups have established themselves in the once-impenetrable Middle East Note: NA is for all drugs not just narcotics

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

But do they work? • Popularity does not equal effectiveness • Most forms of recovery-oriented intervention have not been well-evaluated • However, a sizable evidence base has accumulated regarding 12 -step oriented interventions

Selected data on clinical and costeffectiveness* *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 • 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 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 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.

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.

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 Source: see Humphreys, K. (2004). Circles of Recovery: Self-help organisations for addictions. Cambridge University Press, for a review.

Studies of cost consequences

Incorporating mutual-help principles in to 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.

Total alcohol-related health care costs over three years by comparable alcoholic individuals who initially chose Alcoholics Anonymous or professional outpatient treatment AA group (n=135) mean Outpatient group (n=66) F mean (df=1, 199) Per person costs Years 2 and 3 £ 1, 100 £ 3, 100 £ 1, 000 Total £ 2, 200 £ 4, 100 Year 1 5. 52* Note *p<. 05 Humphreys, K. , & Moos, R. (1996). Reduced substance abuse-related health care costs among voluntary participants in Alcoholics Anonymous. Psychiatric Services, 47, 709 -713. Inflated to 2012 prices and converted to approximate pounds sterling.

Alcohol-related outcomes of 201 individuals initially selecting AA (n = 135) or outpatient treatment (n = 66)

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

Design • 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

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 cognitivebehavioral 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

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, 711716.

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) 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.

Clinical and Policy Implications

12 -step group involvement of 2, 045 substance-dependent veterans after 12 -step or cognitive-behavioral treatment 100 75 66% 60% % 50 58% 45% 48% 36% Cog Beh 25 18% 12 -Step 0 attended meetings had sponsor read 12 -step literature had a friend who Attends AA/NA 12 -step self-help group involvement Note: Involvement was measured one year after discharge by patient reports of activities in the past 3 months. Data in this table were drawn from Humphreys et al. (1999), Alcoholism: Clinical and Experimental Research, 23 , 558 -563.

“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 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 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. • Benefits of 12 -step groups mediated both by psychological and social changes. • Other recovery mutual help organisations should be more greatly studied. • Applying these findings in treatment settings should improve outcomes and reduce costs. • A modest investment in self-help supportive infrastructure would likely more than pay for itself and yield significant public health gains.