Circles of Recovery: Mutual help Organizations for Substance Use Disorders

Keith Humphreys Professor of Psychiatry, Stanford University

Career Research Scientist, U.S. Veterans Health Administration

31 March 2015 School of Social Service Administration

University of Chicago

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 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: Blue Cross •  France: Vie Libre •  Hong Kong: SAARDA •  Japan: Danshukai •  Poland: Abstainer’s Clubs •  Sweden: The Links •  Iran: Narcotics Anonymous

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

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Note: Based on MIDUS survey (N=3032)

Source: Kessler, R.C. et al., 1997, Patterns and correlates of self-help group membership in the United States. Social Policy, 27, 27-46.

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

8.1%

16.5%

35.3%

40.1% Self-help

General Medical

Human Services

Mental HealthSpecialty

Source: Kessler, R.C. et al. (1997). Differences in the use if psychiatric outpatient services between the U.S. and Ontario. NEJM. 336. 551-557.

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, 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 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

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 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, peer-managed 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

0

10

20

30

40

50

60

70

80

Abstinent Employed Incarc

OHTAU

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 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% 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 cognitive-behavioral principles and placed little emphasis on self-help activities

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 self-help 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 (%)

0102030405060708090

Abstinent No SA Prob Pos MH

12-stepCog-Beh

Note: Abstinence higher in 12-step, p< .001

1-Year Treatment Costs, Inpatient Days and Outpatient visits

0 5 10 15 20 25

OP Visits

IP Days

$1000 costCog-Beh12-step

Note: All differences significant at p <.001

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)

What mediates these benefits?

B “mediates” the relationship between A and C

A>>>>>>>>>àB>>>>>>>>àC

Note All paths significant at p<.05. Goodness of Fit Index = .950, Annals of Behavioral Medicine, 21: 54-60

Self-Help Group

Involvement

Reduced Substance

Use

Active Coping

General Friendship Quality

Friends’ Support For Abstinence

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

Motivation to change

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

0102030405060708090

100

%friends in 12S %Abstainers

12-stepNon

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

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: 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 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 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.

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Visi

ts to

sel

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oups

Oakland (prior tointervention)Oakland (duringintervention)Los Angeles (priorto intervention)Los Angeles(during intervention)

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

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. •  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!