keith humphreys veterans affairs and stanford university medical centers palo alto, california...
TRANSCRIPT
KEITH HUMPHREYS
VETERANS AFFAIRS AND STANFORD UNIVERSITY MEDICAL CENTERSPALO ALTO, CALIFORNIA
Recovery from Addiction, Health Care Policy and Longitudinal Research
Acknowledgements
Betty Ford Institute
National Institute of Alcohol Abuse and Alcoholism
Department of Veterans Affairs
Friends, Colleagues and Research Participants in Recovery from Addiction
What is Recovery?
1 A process/outcome for addicted individuals
2 A group of interventions/services
3 A set of values and ideas
4 A cultural and political movement
A Process/Outcome for Addicted Individuals
Betty Ford Institute Consensus Conference:
“Recovery from substance dependence is a voluntarily maintained lifestyle characterized by sobriety, personal health and citizenship.”
A Group of Interventions/Services
Alcoholics Anonymous, LifeRing, Women for Sobriety & other peer-led mutual help organisations
Recovery Schools Oxford House and other forms of sober residence Recovery coaching Faith communities centered on recovery Recovery industries Community support & service & living centres Dry bars, sober cafés/clubs
Recovery* Values and Ideas
Treatment is a good thing, but treatment is not recovery
Addiction is real disorder worthy of health care
Addiction tends to be chronic and encompassing
There is hope for addicted people
Addicted people have strengths, including the ability to become responsible managers of their condition
*Not unique either to recovering people or titular recovery services
Recovery as a Cultural/Political Movement
Health Care Policy Currents
Recovery support services growing rapidly but small in absolute size
Affordable Care Act and Parity Legislation allowing expansion of billing for such services
SAMHSA advocating for SA/MH merged definition
More broadly, political zeitgeist is away from stigmatization, endless punishment
This presentation was prepared in June...apologies if the SCOTUS has since ruined this slide!
Recovery Research Opportunities
The movement, its ideas and values are a rich subject for ethnographic research and sociological analysis
History of the movement and its leaders worthy of serious study
Narrative/phenomenological research on identity change has a strong base upon which to build
Quantitative, longitudinal research can exploit different, but equally important opportunities
What Do We Know?
Oxford Houses and 12-step facilitation interventions (AA/NA/CA) are effective at reducing AOD consumption, improving psychosocial outcomes
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% FemaleFollow-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
OH
TAU
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.
What Do We Know?
Oxford Houses and 12-step facilitation interventions (AA/NA/CA) are effective at reducing AOD consumption, improving psychosocial outcomes
To the limits of widely used statistics, naturalistic studies of AA/NA show it is broadly beneficial in years 0-3
Example study of two groups of matched patients (Humphreys & Moos, 2001, ACER, 25, 711-716)
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
1-Year Clinical Outcomes (%)
0
10
20
30
40
50
60
70
80
90
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
What Do We Know?
Oxford Houses and 12-step facilitation interventions (AA/NA/CA) are effective at reducing AOD consumption, improving psychosocial outcomes
To the limits of widely used statistics, naturalistic studies of AA/NA show it is broadly beneficial in years 0-3
There is clearly a market for other forms of recovery-oriented services
What Don’t We Know
What we need to know in two areas
What we need to know about recovery mutual help organizations*
What we need to know about most other sorts of recovery intervention
*Restricted to 12-step oriented groups, others are underresearched
0
50
100
150
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250
TxEntry 1 year 3 years 5 years
# o
f A
A m
eeti
ng
s, p
st y
r
declining AAhigh AAmedium AAlow AA
AA meeting trajectories
Kaskutas et al., ACER 2005Dependent treatment seekersn = 349
Addictions are Analogous to Cancers in Some Ways But
Cancer researchers/clinicians can answer two critical policy and patient questions that addiction specialists can’t
(1) What is my risk for recurrence after different periods of abstinence?
(2) When is the time for safe stepping down after high intensity care followed by extensive care followed by monitoring?
Styles of Post-Meeting Going Among Long-term Recovering People
Network of recovering friendsSponsorship as a form of ministryFocus on recovery quality rather than meeting
quantityTransfer into a spiritual/religious organizationRich life outside successfully competes with
AAp.s. Officially this doesn’t happen, but
everyone knows it does
But When is it Safe to Step Down, and for Whom?
We don’t know exactly (kind of data we need)
It’s a number of years rather than monthsIt varies depending on severity of problem,
social capital, other problemsIt varies based on alternative opportunitiesWhat helps the individual may disadvantage
the organization and newer membersBut the point is, that contrary to what one
hears, it happens
Basic unanswered questions about other recovery-oriented services
Do recovery schools work?Do recovery business work?Do recovering community centers work?Do recovery coaches work?Etc.
Basic unanswered questions about other recovery-oriented services
Do recovery schools work?Do recovery business work?Do recovering community centers work?Do recovery coaches work?Etc.Innovation is exciting and welcome, and we
can’t have evidence prior to practice. But now that we have new practices, we have the responsibility to evaluate them in prospective outcome studies
An Important Distinction Regarding Evaluation of New Forms of Service
A common clinical standard is that to be accepted as an innovation, a treatment must prove better on average than current practice
But the population standard is (a) Does someone want it? And (b) Is it “good enough”?
Examples: Women-only services, faith-based services
Thank you for your attention!