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Peer Power and Recovery from Addiction. Presented at the European Federation of Therapeutic Communities Oxford, UK. Keith Humphreys Professor of Psychiatry Veterans Affairs and Stanford University Medical Centers Palo Alto, California. - PowerPoint PPT Presentation

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  • Peer Power and Recovery from AddictionKeith HumphreysProfessor of PsychiatryVeterans Affairs and Stanford University Medical CentersPalo Alto, CaliforniaPresented at the European Federation of Therapeutic CommunitiesOxford, UK

  • What is the Relevance of 12-step mutual aid organizations to therapeutic communities?Fundamental shaper of philosophy and approach historically

    A continuing influence on many individual members and staff

    Sharing of certain basic assumptions

  • Mutual Help Organizations and Therapeutic Communities: Shared AssumptionsThe Power of Peers

    The Conceptualization of Addiction

    The Concept of Recovery

    The Emphasis on Long-Term Intervention

    Optimism about Addicted People

  • Estimated substance-related self-help/mutual aid organizations (12 step in red)Estimated Number of Groups WorldwideAlcoholics Anonymous101,000Al-Anon30,000Narcotics Anonymous21,000Cocaine Anonymous 2,000LifeRing/Secular Organization for Sobriety 1,800Adult Children of Alcoholics 1,500Marijuana Anonymous 1,000SMART Recovery 1,000Moderation Management 500Women for Sobriety 350Sources: White and Madara (1998). Self-help sourcebook. Denville, NJ: American Self-help clearinghouse; Humphreys, K. (2004). Circles of Recovery: Self-Help Organizations for Addictions. Cambridge, UK: Cambridge University Press; Consultation with Experts in Field.

  • Note: NA is for all drugs not just narcotics12-step groups have established themselvesin the once-impenetrable Middle East

  • Selected data on clinical and cost-effectiveness

  • Clinical trial of Oxford HouseOxford House is a 12-step influenced, peer-managed residential setting in which almost all patients attend AA/NA150 Patients randomized after inpatient treatment to Oxford House or TAU77% 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 outcomesJason 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 outpatients345 VA outpatients randomized to standard or intensive 12-step group referral81.4% FU at 6 monthsHigher rates of 12-step involvement in intensive conditionOver 60% greater improvement in ASI alcohol and drug composite scores in intensive referral conditionSource: 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.

  • Intreatment preparation for AA produces better outcomesON/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 MAAEZSource: Kaskutas, L.A., et al. (2009). Journal of Substance Abuse Treatment, 37, 228-239.

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

    Chart1

    1243

    103.73.1

    123.41.8

    11.13.32.2

    10.943.3

    8.33.43.35

    0

    AA

    OP

    AA

    OP

    AA

    OP

    Ounces of Ethanol/day

    Days Intoxicated in past month

    Alcohol Dependence Symptoms

    Sample was 87% Caucasian, 49% Female, 52% employed, similar on demographic and problem variables at baseline.Source: Humphreys, K., Moos, R.H. (1995). Reduced substance abuse related health-care costs among voluntary participants in Alcoholics Anonymous. Psychiatric Services, 47, 709-713.

    Baseline

    1 Year

    3 Year

    Sheet1

    Baseline12101211.110.98.3

    1 Year43.73.43.343.4

    3 Year33.11.82.23.33.35

  • Total alcohol-related health care costs over three years by comparable alcoholic individuals who initially chose Alcoholics Anonymous or professional outpatient treatmentAA groupOutpatient group(n=135)(n=66)FmeanSDmeanSD (df=1,199)

    Per person costsYear 1$1,115$2,386$3,129$4,355Years 2 and 3$1,136$4,062$948$2,852Total$2,251$5,075$4,077$5, 3715.52*

    Note *p

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

  • DesignFollow-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 activities5 programs were based on cognitive-behavioral principles and placed little emphasis on self-help activities

  • Self-help group participation at 1-year follow-up was higher after self-help oriented treatment36% 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 (%)Note: Abstinence higher in 12-step, p< .001

  • 1-Year Treatment Costs, Inpatient Days and Outpatient visitsNote: All differences significant at p
  • 2-year follow-up of same sample50% 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)

  • UK SMART expansion projectPartnership between DoH, Alcohol Concern and SMART Recovery UKDeveloped training, local champions, referral processes in 6 sites in EnglandEstablished 18 groups in 4 regions (12 original, 6 spinoffs)Raised profile of SMART with professionals and publicSource: Macgregor, S., & Herring, R. (2010). The Alcohol Concern SMART Recovery pilot project final evaluation report. Middlesex University.

  • What mediates these benefits?

  • B mediates the relationship between A and CA>>>>>>>>>B>>>>>>>>C

  • Note

    All paths significant at p

  • Partial mediators of 12-step groups effect on substance use identified in researchIncreased self-efficacyStrengthened commitment to abstinenceMore active copingEnhanced social supportGreater spiritual and altruistic behaviorReplacement of substance-using friends with abstinent friends

  • 12-step vs. non-12 step based friendship networks of 1,932 treated SUD patientsSource: 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.

  • Summary of What We Know12-step group participation significantly reduces drug and alcohol use.

    12-step group involvement reduces surplus health care utilization.

    Benefits of 12-step groups mediated both by psychological and social changes.

  • Implications for TCsBasic principles of 12-step groups that are shared with TCs have empirical support

    12-step oriented TCs can improve outcomes and reduce costs by facilitation 12-step group involvement

  • Thank you for your attention!

    ***********

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