Transcript Effectiveness and mediators of 12

The Evidence Base on PeerManaged 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
40.1%
Self-help
8.1%
General Medical
Human Services
16.5%
Mental Health
Specialty
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.
35.3%
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
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
• 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
OH
TAU
40
30
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 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
£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 1year 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 (%)
90
80
70
60
50
12-step
Cog-Beh
40
30
20
10
0
Abstinent
No SA Prob
Note: Abstinence higher in 12-step, p< .001
Pos MH
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.
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%
48%
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 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.
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
Visits to self-help groups
2500
2250
Oakland (prior to
intervention)
Oakland (during
intervention)
Los Angeles (prior
to intervention)
Los Angeles
(during intervention)
2000
1750
1500
1250
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.
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.