Transcript Effectiveness and mediators of 12

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
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
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Austria:
France:
Hong Kong:
Japan:
Poland:
Sweden:
Iran:
Blue Cross
Vie Libre
SAARDA
Danshukai
Abstainer’s Clubs
The Links
Narcotics Anonymous
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.
Any
Other
Family
Physical
Illness/Disease
Emotional
Crisis
Eating
Problems
20
18
16
14
12
10
8
6
4
2
0
Substance
Problems
Lifetime and past 12 months participation
in self-help groups, 1995
Past 12 mos.
Lifetime
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
• However, a sizable evidence base has
accumulated regarding 12-step oriented
interventions
Background on AA, the
prototypic 12-step organization
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•
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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, 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
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.
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 cognitivebehavioral 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 1year 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 (%)
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
1-Year Treatment Costs, Inpatient
Days and Outpatient visits
$1000 cost
Cog-Beh
12-step
IP Days
OP Visits
0
5
10
15
Note: All differences significant at p <.001
20
25
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>>>>>>>>>B>>>>>>>>C
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
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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
100
90
80
70
60
50
40
30
20
10
0
12-step
Non
%friends in 12S
%Abstainers
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.
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.
• 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!