treating addiction as a chronic disease

Treating Addiction as a chronic disease

John F. Kelly, Ph.D. Elizabeth R. Spallin Associate Professor of Psychiatry in Addiction Medicine

Harvard Medical School

Director Recovery Research Institute

MGH Center for Addiction Medicine

Faxton St. Lukes, October 17th 2014

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RECOVERY RESEARCH INSTITUTE LAUNCHOCTOBER 30, 2013

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OUTLINE

Definitions, terminology, and

stigma

Acute vs chronic care model

Conceptualizations of addiction and

recovery

Addiction recovery management

models

OUTLINE

Definitions, terminology, stigma, and

discrimination

HEALTH CARE IS CHANGING AND SUD IS (FINALLY) BECOMING AN IMPORTANT FOCUS IN THAT CHANGE

DEFINITIONS, TERMINOLOGY, STIGMA AND DISCRIMINATION

Should we use the term “Chronic disease”? Or, “alcohol/drug problem? Or call it “substance abuse/abuser”?

Does it really matter what we call it or them?

Is it chronic? Is it a “disease”?

WHAT IS A “DISEASE”?“a disordered or incorrectly functioning organ, part,

structure, or system of the body resulting from the effect of genetic or developmental errors, infection,

poisons, nutritional deficiency or imbalance, toxicity, or unfavorable environmental factors.” – Dictionary.com

“ a condition of the living animal or plant body or of one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms” -Miriam Webster

It matters, because the words we use influence our conceptualizations and approaches to it (e.g., “War on drugs” “You use you lose” vs addiction as a public health problem)

“CHRONIC”?WHO (2014)

“Noncommunicable diseases (NCDs), also known as chronic diseases, are not passed from person to person. They are of long duration and generally slow progression. The four main types of noncommunicable diseases are cardiovascular diseases (like heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructed pulmonary disease and asthma) and diabetes.”

NOT ALL THOSE WHO MEET CRITERIA FOR SUD HAVE CHRONIC TRAJECTORIES…EPIDEMIOLOGIST’S ILLUSION VS. CLINICIAN'S ILLUSION

NSDUH and Dennis & Scott

0

10

20

30

40

50

60

70

80

90

100

12-13

14-15

16-17

18-20

21-29

30-34

35-49

50-64

65+

No Alcohol or Drug Use

Light Alcohol Use Only

Any Infrequent Drug Use

Regular AOD Use

Abuse

Dependence

Age Groups

Severity Category

14

REMISSION OF DEPENDENCE IS COMMON, BUT FOR SOME INDIVIDUALS’ DEPENDENCE CAN SPAN DECADES

Source: NIAAA 2001-2002 NESARC data (18-60+ years of age) and SAMHSA 2003 NSDUH (12-17 years of age).

High remission

rates

But for some, chronic, harmful course…

SUBTYPES – BUT IDENTIFICATION OF CLINICALLY MEANINGFUL SUBTYPES CHALLENGING…TYPOLOGY INVESTIGATIONS

Silkworth (1939) Jellinek (1960) Cloninger (1981) Babor (1992) Del Boca (1994) Del Boca (1996) Hesselbrock (2006) Moss (2007) Anton (2008)

Addiction Onset

Help Seeking

Full Sustained

Remission (1 year

abstinent)

Relapse Risk drops below

15%

4-5 years 8 years 5 years

Self-initiated cessatio

n attempt

s

4-5 Treatmen

t episodes/mutual-

help

Continuing care/mutual-

help

For more severely dependent individuals … course is chronic but remission most likely outcome

60% of individuals

with addiction

will achieve full

sustained remission (White, 2013)

Opportunity for earlier detection through

screening in non-

specialty settings like

primary care/ED

ADDICTION IS HEAVILY STIGMATIZED AND THE LANGUAGE WE USE MAY AFFECT STIGMA/DISCRIMINATION

• SUDs most stigmatized of all social/health problems Most

Stigmatized

• National surveys show stigma one of main reasons people with SUD do not seek specialty care (SAMHSA, 2009)Nationally

• WHO examined 18 most stigmatized conditions (eg. criminal, HIV, homeless) across 14 different countries (Room et al 2001)• Drug addiction- #1 - most stigmatized• Alcohol addiction- 4th most stigmatized

Internationally

• Ambivalence influenced by stigma and contributes to few accessing care (only 10% seek specialty care/yr)Poor access

LANGUAGE SURROUNDING CLINICAL CARE IN ADDICTION IS UNLIKE ANY OTHER AREA OF MEDICINE - MAY AFFECT QUALITY AND EFFECTIVENESS OF CARE

A patient suffering from diabetes has “an elevated glucose”. A patient with cardiovascular disease has “a positive exercise tolerance test” Someone inside the healthcare system

addresses the results. An “addict” isn’t “clean”—he has been

“abusing” drugs and has a “dirty” urine. Someone outside the system that cares for all

other health conditions addresses the results. In the worst case, the drug use is addressed by

incarceration.

SUD STIGMA/DISCRIMINATION MODERATED BY TWO FACTORS…

CAUSE Did they cause it?

“It’s not their fault” (decreases stigma; increase compassion)

CONTROLLABILITY Can they help it?

“They can’t help it” (decreases stigma; increases compassion)

TWO COMMONLY USED TERMS…

Referring to someone as…

“a substance abuser” – implies perpetration/willful misconduct (they CAN help it)

“having a substance use disorder” – implies victim/medical malfunction (they CAN’T help it)

22

How we talk and write about these conditions and individuals suffering them does matter

Mr. Williams is a substance abuser and is attending a treatment program through the court. As part of the program Mr. Williams is required to remain abstinent from alcohol and other drugs. He has been doing extremely well, until one month ago, when he was found to have two positive urine toxicology screens which revealed drug use and a breathalyzer reading which revealed alcohol consumption. Within the past month there was a further urine toxicology screen revealing drug use. Mr. Williams has been a substance abuser for the past six years. He now awaits his appointment with the judge to determine his status.

Mr. Williams has a substance use disorder and is attending a treatment program through the court. As part of the program Mr. Williams is required to remain abstinent from alcohol and other drugs. He has been doing extremely well, until one month ago, when he was found to have two positive urine toxicology screens which revealed drug use and a breathalyzer reading which revealed alcohol consumption. Within the past month there was a further urine toxicology screen revealing drug use. Mr. Williams has had a substance use disorder for the past six years. He now awaits his appointment with the judge to determine his status.

Doctoral-level clinicians (n=561) randomized to receive one of two terms….

24

0.41 0.76 0.21 0.670.23 0.42 0.24 0.79 0.330.67 0.580.69.00

.10

.20

.30

.40

.50

.60

.70

.80

.90

Treatment Punishment Social Threat AttributionBlame

AttributionExoneration

Self-Regulation

Mea

n of

Sub

scal

e Sc

ores

Substance Abuser Substance Use Disorder

Figure 1. Subscales comparing the “substance abuser” and “substance use disorder” descriptive labels

Kelly, JF, Dow, SJ, Westerhoff, C. Does our choice of substance-related terms influence perceptions of treatment need? An empirical investigation with two commonly used terms (2010) Journal of Drug Issues

IMPLICATIONS

Exposure to the “abuser” term may activate an implicit more punitive cognitive bias

Learn from our friends in other fields : Individuals with “eating related problems” are

uniformly described as “having an eating disorder” NEVER as “food abusers”

STOP TALKING “DIRTY”: CLINICIANS, LANGUAGE, AND QUALITY OF CARE FOR THE LEADING CAUSE OF PREVENTABLE DEATH IN THE UNITED STATESKELLY, JF, WAKEMAN, SE, SAITZ, R. AMERICAN JOURNAL OF MEDICINE (IN PRESS)

Avoid stigmatizing terminology such as “dirty” vs “clean” utox screens, instead of “negative/positive”.

Recommendations: Use “person first” language - refer to individuals with

addiction as people with a “substance use disorder” not as substance “abusers” or “addicts.”

For those with consequences or risk, but not a disorder (often referred to inaccurately as “abuse”), use “hazardous”, “risky”, or “harmful” use, or for the full spectrum that includes risk to a disorder, “unhealthy” use.

…commit to a medically appropriate lexicon which conveys the same dignity and respect we offer to other individuals suffering from an array of medical problems.

OUTLINE

Acute vs chronic care model

Addiction Onset

Help Seeking

Full Sustained

Remission (1 year

abstinent)

Relapse Risk drops below

15%

4-5 years 8 years 5 years

Self-initiated cessatio

n attempt

s

4-5 Treatmen

t episodes/mutual-

help

Continuing care/mutual-

help

For more severely dependent individualscourse of addiction is chronic …

60% of individuals

with addiction

will achieve full

sustained remission (White, 2013)

Opportunity for earlier detection through

screening in non-

specialty settings like

primary care/ED

If really believed addiction is chronic we would not: View prior tx failure as a poor prognostic indicator Convey the expectation that all clients should achieve

complete, enduring sobriety following single, brief treatment episode

Punitively d/c clients for becoming symptomatic/confirming their diagnosis

Relegate continuing care to an afterthought Terminate the service relationship following acute care Treat serious and persistent SUD in serial episodes of

self-contained and unlinked interventions

BUT, WHAT IF REALLY BELIEVED ADDICTION WAS A CHRONIC DISORDER?

White and Kelly (2011)

CHRONIC NATURE OF SUBSTANCE DEPENDENCE MAKES IT WELL-SUITED TO ONGOING RECOVERY MANAGEMENT (RM) APPROACHES…

Addiction talked as chronic but still treated as acute condition:

Recovery management is a philosophy of organizing addiction treatment and recovery support services to enhance early pre-recovery engagement, recovery initiation, long-term recovery maintenance…(White & Kelly, 2011).

OUTLINE

Conceptualizations of addiction and

recovery

ADDICTION IS A… A disease of the brain that affects the neuro-circuitry

of reward, memory, motivation, impulse control, and judgment

For recovery to occur, accurate risk appraisals must be conducted and frequent adaptive decisions made and actions taken (prefrontal cortex) to inhibit impulses and gradually correct dysregulated reward system (limbic system)

Rewards of use are immediate, concentrated, predictable; rewards of recovery are delayed, diffuse, and variable

Recovery is a demanding, effortful, process requiring constant vigilance to protect against the risk of relapse and can lead to frustration and exhaustion…

WHY DO PEOPLE HAVE A HARD TIME STAYING SOBER AND IN REMISSION?

General Adaptation Syndrome (Selye, 1956)

Alarm – Resistance – Exhaustion

“… after self-control efforts, subsequent attempts at self-control are more likely to fail. Continuous self-control efforts, such as vigilance, also degrade over time…These decrements appear to be specific to behaviors that involve self-control (Muraven & Baumeister, 2000).

Post-acute withdrawal and need to learn complex recovery coping skills – stressful; taxes available coping resources - affects relapse risk

Need to find ways to replenish cognitive resources to inhibit thoughts and impulses to use substances over time…

WHY DO PEOPLE HAVE A HARD TIME STAYING SOBER AND IN REMISSION?

In fact, the recovery construct, like the addiction construct, is made up of two reciprocal factors: “remission” and the consequences of that remission, “recovery capital”;

as longer remission is achieved, more capital accrues, BUT also, remission can be influenced the other way - as more recovery capital accrues so the chances of continued remission increase.

Kelly and Hoeppner (2014) A biaxial formulation of the recovery construct, Addiction Research and Theory

35

DECREASE STRESS AND REPLENISH COPING RESOURCES BY PROVIDING RM AND RECOVERY SUPPORT SERVICES

Recovery Management and Monitoring

Recovery Mutual-help organizations

Recovery High schools

Collegiate Recovery Support programs

Recovery Community Centers

Recovery Community Organizations

OUTLINEAddiction recovery

management models

Clinically, we’ve learned that

prized-based CM approaches can produce large effects while

contingencies in place …. But advantage

disappears by 6m once removed

Examples of Long-term recovery management programs

Physicians Health Programs

Hawaii Opportunity Probation with Enforcement (HOPE)

South Dakota “24/7”

Clinical Recovery Management Check-ups

Mutual-help organizations

PHYSICIANS HEALTH PROGRAMS

Emerged in 1970s, through the American Medical Association to help alcohol/drug impaired physicians

Services provided include:- professional intervention services- referral to formal evaluation- referral to formal treatment- long-term monitoring

Source: White, W.L., DuPont, R.L. & Skipper, G.E. (2007)

KEY INGREDIENTS OF PHPS motivational fulcrum: link recovery to positive rewards and

relapse to negative consequences (e.g., loss of license) comprehensive assessment and treatment: patient-oriented

treatment rather than a fixed model care management oversight role: PHPs directs care for

physicians so they can select appropriate resources high expectation for abstinence-based recovery: relapses are

seen as temporary setbacks/learning experiences assertive linkage to recovery support groups: active referrals

to 12-step and other recovery-focused mutual aid groups sustained monitoring support reintervention: periodic

interviews/random urine testing over 5 years reintervention at higher level of intensity: relapse and

reintervention are followed by reevaluation and more intensive/prolonged treatment

integrated comprehensive program: PHPs include these items in an integrated and long-sustained program

Source: Skipper, G.E. and DuPont, R.L. (2011)

PHPS 5-7YR STUDY OUTCOMES (N=904)

72% completed the contract; a further 22% signed a new one

(78% of these voluntarily)

79% licensed and working at 5-year follow-up

92% participated in AA or NA; 61% participated in continuing

groups

78% had zero positive tests across 5-7 yrs; 22% had at least one positive test at some point, however, only 1 in 200 drug screens were positive over the 5-7yr monitoring period

Source: Du Pont, R.L. et al. (2011)

HAWAII OPPORTUNITY PROBATION WITH ENFORCEMENT (HOPE) PROGRAM

Goal - to reduce drug use, new crimes, and incarceration

Drug-testing-and-sanctions approach

Does not mandate treatment; 12-step participation encouraged

Started as pilot program 2004 with 36 offenders now expanded to over 1500 participants 2009

PILOT STUDY BY THE INTEGRATED COMMUNITY SANCTIONS UNIT IN HONOLULU

Offenders in HOPE vs. comparison offenders

HOPE procedure:- initiation/overview conducted by judge- call HOPE hotline every morning- if selected for testing, must appear by 2pm- if fail to appear or test positive, “Motion to Modify Probation” issued- after immediate hearing, if offender has violated probation, sentenced to short jail stay (several days)- HOPE participation resumes upon release

Probation as usual:- no random drug testing- scheduled appointments with a probation officer once a month

AVERAGE NUMBER OF POSITIVE UAS, BY PERIOD. (HAWKEN ET AL. , 2009)

In a 12-month period 61% of HOPE participants had zero positive UAs

Note: Data are from PROBER. For comparison probationers, data reflect urinalysis results for

regularly scheduled UAs. For HOPE probationers UAs include regularly scheduled tests, and

random testing. Pre (3m) refers to the average number of missed appointments in the three

months before the study start date (baseline). Follow-up (3m) refers to the average number of

missed appointments in the three-month period following baseline and Follow-up (6m) refers to

the average number of missed appointments in the six-month period following baseline.

RANDOMIZED CONTROLLED TRIAL OF HOPE (N=493) (HAWKEN ET AL., 2009)

HOPE vs. probation-as-usual One year follow up

ResultsHOPE in comparison with probation-as-usual:- 60% fewer no-shows- 70% fewer positive urine tests- 55% fewer new arrest rates- 53% lower revocation rate- 48% lower incarceration

SOUTH DAKOTA’S “24/7 SOBRIETY” PROJECT (LARRY LONG)

For repeat DUI offenders Started 1980s in 1 county; 2007 implemented

state-wide -replicated in North Dakota Objective verification of abstinence (twice

a day breath, blood or other bodily substance testing

Positive/missed tests results in immediate 24-hour incarceration

No treatment referral or requirement; 12-step attendance encouraged

24/7 SOBRIETY OUTCOMES

Urinalyses (July 1, 2007-July 20, 2011): N= 1,990 46,648 tests administered Pass Rate 96.9% SCRAM bracelets (Nov. 6, 2006-July 20, 2011): N=3,177 77.9% had no violations 22.1% participants had some type of violationDrug patches (July 1, 2007-July 20, 2011): N=94 Pass Rate 80%

Source: http://apps.sd.gov/atg/dui247/247stats.htm

A Example of the benefit of treating addiction like a chronic condition: 4-year outcomes from the Early Re-Intervention experiment using Recovery Management Checkups

N=446 adults with SUD, mean age = 38, 54% male, 85% African-American

randomly assigned to

quarterly assessment onlyquarterly assessment plus RMC

Recovery Management Checkups Linkage manager who used motivational interviewing to

review the participant’s substance use, discuss treatment barrier/solutions, schedule an appointment for treatment re-entry, and accompany participant through the intake

If participants reported no substance use in the previous quarter, the linkage manager reviewed how abstinence has changed their lives and what methods have worked to maintain abstinence

Source: Dennis & Scott (2012). Drug and Alcohol Dependence, 121, 10-17

RESULTS 1RETURN TO TREATMENT

• Participants in RMC condition sig. more likely to return to treatment sooner

Source: Dennis & Scott (2012). Drug and Alcohol Dependence, 121, 10-17

RESULTS 4DAYS ABSTINENT (0-1350)

Total days abstinent*880

900

920

940

960

980

1000

1020

1040

RMC Control

*p<.01

Of 18 vars tested, the only variables that predicted return to treatment was the

intervention

WHAT ABOUT MHOS’ ROLE IN CHRONIC RECOVERY MANAGEMENT?

SOCIETAL RESPONSE TO SUD AND RELATED PROBLEMS. WHY HAVE MHO’S GROWN DESPITE BETTER MORE EFFECTIVE

PROFESSIONAL TREATMENTS

While increases in quality and quantity of SUD treatment over past 40yrs….

…professional resources alone cannot cope; stigma and cost present further barriers to formal tx access

Addiction often has chronic course (8 yrs from 1 st tx to achieve FSR; Dennis et al, 2005); 4-5 yrs before risk of relapse <15%

In tacit recognition, most societies seen increases in MHOs during past 75 yrs (Kelly & Yeterian, 2008)

“The burden of alcohol problems is a heavy one; the specialized treatment sector is necessarily limited in size and quite costly.

The committee believes that only a shared effort can succeed in

lifting this burden to any significant degree” (IOM, 1990)

POTENTIAL ADVANTAGES OF COMMUNITY MUTUAL-HELP IN RECOVERY MANAGEMENT

Cost-effective -free; attend as intensively, as long as desired

Focused on addiction recovery management over long term

Widely available, easily accessible/flexible

Provide access at high risk times when professional services not available (e.g., nights/ weekends/holidays)

Entry threshold (no paperwork, insurance); anonymous (stigma)

Adaptive community based system that is responsive to undulating relapse risk

NameYear of Origin Number of groups in U.S. Location of groups in U.S.

Alcoholics Anonymous (AA) 1935

60,000all 50 States

Narcotics Anonymous (NA) 1940s

Approx. 20,000all 50 States

Cocaine Anonymous (CA) 1982

Approx. 2000 groups most States; 6 online meetings at www.ca-online.org

Methadone Anonymous (MA) 1990s Approx. 200 groups

25 States; online meetings at http://methadone-anonymous.org/chat.html

Marijuana Anonymous (MA) 1989 Approx. 500 groups

24 States; online meetings at www.ma-online.org

Rational Recovery (RR)

1988No group meetings or mutual helping; emphasis is on individual control and

responsibility-----------------------------------------------------

Self-Management and Recovery Training

(S.M.A.R.T. Recovery)

1994 Approx. 500 groups 40 States; 19 online meetings at

www.smartrecovery.org/meetings/olschedule.htm

Secular Organization for Sobriety, a.k.a.

Save Ourselves (SOS)1986 Approx. 500 groups

all 50 States; Online chat at www.sossobriety.org/sos/chat.htm

Women for Sobriety (WFS) 1976 150-300 groups

Online meetings at http://groups.msn.com/ WomenforSobriety

Moderation Management (MM) 1994 Approx.18 face-to-face meetings

12 States; Most meetings are online at www.angelfire.com/trek/mmchat/;

MHOs are prolific resources well-suited to RM approaches to SUD

Source: Kelly & Yeterian, 2008

http://www.ca-online.org/

http://methadone-anonymous.org/chat.html

http://www.ma-online.org/

http://www.smartrecovery.org/meetings/olschedule.htm

http://www.sossobriety.org/sos/chat.htm

http://groups.msn.com/%20WomenforSobriety

http://www.angelfire.com/trek/mmchat/

Table 2. Dual-Diagnosis Focused Mutual-help Groups

Name Year of OriginNumber of

groups in U.S. Location of groups in U.S.

Double Trouble in Recovery

(DTR)1989 300

Highest number of groups in NY, GA, CA, CO, NM, FL

Dual Recovery Anonymous

(DRA)1989 445 Highest number of groups in

CA, OH, PA, MA

Dual Disorders Anonymous 1982 98 28 in IL

Dual Diagnosis Anonymous

(DDA) 76 38 in CA

Source: Kelly & Yeterian, 2008)

Table 3. Non-Substance Focused Addictive Behavior Mutual-help Groups

NameYear of Origin

Number of groups in U.S. Location of groups in U.S.

Gamblers Anonymous

(GA)1957 Approx. 1000 chapters all 50 States

Sex Addicts Anonymous

(SAA)1977 Approx. 700 meetings

most States; Online meetings at www.sexaa.org/online.htm; Telephone

meetings

Sex and Love Addicts

Anonymous (SLAA)

1976Approx. 1320 groups

worldwide

(including in all 50 States), Online meetings at

www.slaafws.org/online/onlinemeet.html

; Regional teleconference calls

Overeaters Anonymous

(OA)1960

Approx. thousands of meetings

all 50 States; Numerous online (www.oa.org/pdf/OnlineMeetingsList.pdf

) and telephone meetings (www.oa.org/pdf/phone_mtgs.pdf)

Source: Kelly & Yeterian, 2008)

http://www.sexaa.org/online.htm

http://www.slaafws.org/online/onlinemeet.html

http://www.slaafws.org/online/onlinemeet.html

http://www.oa.org/pdf/OnlineMeetingsList.pdf

http://www.oa.org/pdf/OnlineMeetingsList.pdf

http://www.oa.org/pdf/phone_mtgs.pdf

Effectiveness: Do they help? Millions attend 12-step MHOs and

many continue long-term

Rigorous experimental, quasi-experimental, correlational, and observational studies support MHOs as stand alone or adjunct to treatment

Potentiate and extend treatment outcomes and reduce health

care costs

Work through mechanisms similar to those operating in formal tx

Clinical (12-step facilitation) strategies can enhance participation and outcomes

EVIDENCE OF BENEFIT - META ANALYSES OF AA 4 meta-analytic reviews

Emrick et al. 1993

Tonigan et al, 1996

Kownacki et al. 1999

Ferri, Amato, & Davoli, 2006

RESULTS AND LIMITATIONS Results from hundreds of studies reveal AA

confers a consistent moderate beneficial effect in par with professional treatment

Results from RCTs of AA itself, reveal mixed findings depending on whether individuals were coerced/mandated to attend AA meetings or not

Most attended following treatment –difficult to discern unique effects of AA…

Odds of Abstinence

4 Months

-Completed treatment -Attended 12-step meetings on a weekly or more basis

-Completed treatment -Did not attend 12-step meetings

-Remained in treatment-Did not complete treatment-Did not attend 12-step meetings

2 Months -Did not complete treatment -Did not attend 12-step meetings

-1 0 1 2 3 4 5 6 7 8 9

Fiorentine and Hillhouse (2000)

CBT TSF$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

$16,000

$18,000

$20,000

$12,129

$7,400$5,735

$2,440

$17,864

$9,840Year 1Year 2Total

HEALTH CARE COST OFFSET CBT VS 12-STEP RESIDENTIAL TREATMENT

Compared to CBT-treated patients, 12-step treated patients more likely to be in recovery, at a $8,000 lower cost per pt over 2 yrs ($15M total savings)

Also, higher remission

rates, means

decreased disease and

deaths, increased quality of

life for sufferers and their families

ADOLESCENT HEALTH CARE COST OFFSET 7-YEAR STUDY

N = 403 adolescents, age 13-18Follow-up: 6 months, 1, 3, 5, and 7 years12-step attendance associated with

better outcomes over the 7 yr period Avg annual medical costs for all participants over 7

years: $3085 per person per year 4.7% decrease in medical costs with each additional

12-step meeting attended = $145 annual savings per 12-step meetings attended

Source: Mundt, Parthasarathy, Chi, Sterling, Campbell (2012)

Mundt et all,, 2012, Drug and Alcohol Dependence

TOWARD TWELVE-STEP FACILITATIONEvidence: Millions have attended; half of AA members of 5 yrs

or more of sobriety; attendees report benefitting

Positive results from more than a hundred correlational/ quasi-experimental and experimental studies

Facilitating linkage enhances abstinence/remission and reduces health care costs

If we really believed addiction was a chronic disease and MHOs were shown to increase remission rates shouldn’t we try to link patients with them?

Can what we do in treatment increase

long-term engagement with MHOs and thereby enhance recovery

outcomes?

DOES FACILITATION DURING TX AFFECT RISK FOR DROPOUT?

Risk Factors

Treatment Settings Combined

High Supportive Treatment milieu

Low supportive Treatment milieu

n Dropout Rate n Dropout Rate n Dropout Rate 0 261 30 % (77) 151 30 % (45) 110 29 % (32) 1 548 30 % (163) 274 29 % (79) 274 31% (84) 2 582 38 % (221) 269 38 %(103) 313 38 % (118) 3 512 43 % (218) 176 40 % (70) 336 44% (148) 4 381 51 % (193) 119 42 % (50) 262 55% (143) 5 150 54 % (81) 36 47 % (17) 114 56% (64) 6-7 78 65 % (51) 16 50 % (8) 62 70% (43)

• Dropout rate = 40%• AA dropouts had 3x higher odds of relapse to alcohol/drug use

FACILITATION BY DROPOUT-RISK INTERACTION

Source: Kelly & Moos (2003) Dropout from 12-Step Groups: Prevalence, Predictors and Counteracting Treatment Influences, Journal of Substance Abuse Treatment,24, 241-250

PRECURSOR TO CURRENT TSF RESEARCH (SISSON AND MALAMS, 1981)

20 patients randomly selected from outpatient tx program for alcohol use disorder

Randomly assigned to:1: Standard referral

given information about AA including time, date, location of meetings, encouraged to attend meetings

2: Systematic encouragement and community access In addition to standard procedure, clients had phone

conversation with AA member during a session - client and AA member met before first meeting, member provided client with ride; client also received a reminder phone call from the member

PRECURSOR TO CURRENT 12-STEP FACILITATION RESEARCH

Results: 0% clients in standard referral attended a meeting

during the target week

100% clients in systematic encouragement and community access group attended meeting during target week

Mean AA meeting attendance rate for 4 week period: 0 for standard referral group vs 2.3 for systematic

encouragement group

TSF DELIVERY MODES

Stand alone Independent therapy

Integrated into an existing therapy

Component of a treatment package (e.g., an additional group)

As Modular appendage linkage component

TSF

OTH

TSF DELIVERY MODES




As Modular add-on linkage component

TSF

OTH

I. PROJECT MATCH- RESULTS Similar on continuous outcomes (PDA/DDD) Across txs, AA attendees had better outcomes (Tonigan et al,

2002) AA valuable adjunct to treatment - even when not formally

emphasized Individuals assigned to TSF attended AA more frequently and

had substantially higher rates of continuous abstinence at 1yr and 3yrs

CHANGING NETWORK SUPPORT FOR DRINKING (LITT ET AL., 2009)

Network Support Project -to determine if tx can change social networks to ones supportive of sobriety

Alcohol dependent individuals (N=210) randomly assigned to 1 of 3 txs:

Network Support (NS) Meant to help patients change social network to include people in

support of abstinence; based on TSF treatment created for Project MATCH; 6 core sessions+ 6 elective sessions

Network Support +Contingency Management (NS+CM) Same network support as described above, plus drawings from a

“fishbowl” if soc. network enhancing tasks completed (eg. AA meeting, having coffee with a sober friend)

Case Management (CaseM, control condition) Based on intervention used in Marijuana Treatment Project; therapist

and participant worked together to indentify barriers to abstinence and develop goals and identify resources to be used to aid in achieving abstinence

CHANGING NETWORK SUPPORT FOR DRINKING- FINDINGS

Network Support:

• Higher PDA

• More total abstinent

• Lower consequences

• Lower DDD

TSF DELIVERY MODES





TSF

OTH

STRATEGIES FOR FACILITATING OUTPATIENT ATTENDANCE OF AA (WALLITZER ET AL, 2008)

Approaches to assist in involvement in AA

169 adult alcoholic outpatients randomly assigned to one of three treatment conditions

All clients received treatment that included: 12 sessions Focus on problem-solving, drink refusal,

relaxation Recommendation to attend AA meetings

STRATEGIES FOR FACILITATING OUTPATIENT ATTENDANCE OF AA Treatment varied between 3 conditions in terms of how the therapist

discussed AA and how much information about AA was shared Condition 1: Directive approach

Therapist directed Client signed contract describing goals to attend AA meetings Therapist encouraged client to keep a journal about meetings Reading material about AA provided to client Therapist informs client about skills to use during meetings and about using a

sponsor 38% total material covered in sessions was about AA

Condition 2: motivational enhancement approach (more client centered)

Therapist obtains clients feelings and attitudes about AA Therapist describes positive aspects of AA, but states that it is up to the client how

much they will be involved Therapist intends to assist the client in making a decision in favor of AA 20% total material covered in sessions about AA

Condition 3: CBT treatment as usual, no special emphasis on AA Throughout treatment, therapist briefly inquires about AA and encourages client to

attend AA 8% total material covered in sessions about AA

Walitzer, Dermen & Barrick, 2009

STRATEGIES FOR FACILITATING AA ATTENDANCE DURING OUTPATIENT TREATMENT

Strategies for Facilitating AA Attendance during Outpatient Treatment

TSF DELIVERY MODES





TSF

OTH

MAAEZ INTERVENTION (KASKUTAS ET AL, 2009) Making AA Easier- manual guided - designed to help clients

prepare for AA

Goal: to prepare for AA (encourage participation in AA, minimize resistance to AA, and educate about AA) MAAEZ intervention is conducted in a group format to help prepare

for group dynamic of AA

Facilitator goal: to inform clients about AA and facilitate group interaction Facilitator recommended to be an active member of AA, NA, or CA

Discussion format: MAAEZ allows and encourages feedback (referred to as “cross-talk” in MAAEZ), unlike AA which does not allow feedback

MAAEZ INTERVENTION- FINDINGS

TSF DELIVERY MODES





TSF

OTH

EFFECTIVENESS OF CLINICIAN REFERRALS TO AA (TIMKO ET AL 2006; 2007)

Evaluation of procedures to effectively refer patients to 12-step meetings

Individuals with SUDs entering a new outpatient treatment program randomly assigned to a treatment condition and provided self reports on meeting attendance and substance use

Condition 1: standard referral Patients given locations and schedules of meetings and encouraged to attend

Condition 2: intensive referral Patients give locations and schedules of meetings, with the meetings preferred

by previous clients indicated

Therapist reviews a handout about program including introduction to 12-step philosophy and common concerns

Therapist arranged a meeting with a current member and client had a phone conversation with this member during a session

Therapist and client agreed on which meetings client will attend and client kept a journal of meetings attended and experiences

EFFECTIVENESS OF CLINICIAN REFERRALS TO AA- AA PARTICIPATION FINDINGS

Timko 2007

EFFECTIVENESS OF CLINICIAN REFERRALS TO AA- ABSTINENCE OUTCOME FINDINGS

Social

Psych

Neuro-biology

RELAPSE

Cue Induced

Stress Induced

Drug Induced

How might informal RM resources like MHOs reduce relapse risk and sustain the recovery process?

AA-related social network changes may help avoid cues, reduce and tolerate distress, and maintain abstinence minimizing drug-induced relapse risks

MHO

Kelly JF, Yeterian, JD, (2013). Mutual help groups. In McCrady and Epstein. Comprehensive Textbook on Substance Abuse.

MHOS REMOTIVATE PEOPLE OVER TIME MHOs help maintain the salience of the negative

consequences of use by facilitating continuous re-exposure (personal stories) and reactivation of painful memories that stimulated the initial recovery attempt (“keep it green”)

MHOs provide exposure to recovering role models and observable evidence that recovery and happiness are attainable

MHOs impart knowledge/skills, realistic expectations of change

MHOs provide encouragement, cheerleading, applause to encourage people to continue; supervision/monitoring

MHOs provide access to new social network that can facilitate alternative sober rewarding activities

(9-mo) Self-efficacyNegative Affect

Baseline (BL) CovariatesAgeRaceSexMarital StatusEmployment Status

Prior Alcohol TreatmentMATCH Treatment groupMATCH study site

Alcohol Outcomes (PDA/DDD)

(15-mo) Alcohol Outcomes(PDA or DDD)

(3-mo) AA attendance

(BL) Self-efficacyNegative Affect

(9-mo) Self-efficacyPositive Social

(BL) Self-efficacyPositive Social

(9-mo) Religious/SpiritualPractices

(BL) Religious/SpiritualPractices

(9-mo) Depression(BL) Depression

(9-mo) Social Network“pro-abstinence”

(BL) Social Network“pro-abstinence”

(9-mo) Social Networkpro-drinking”

(BL) Social Network“pro-drinking”

Source: Kelly, Hoeppner, Stout, Pagano (2012) , Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous: A multiple mediator analysis. Addiction 107(2):289-99

97

Self-efficacy (NA)5%

Depression3%

Spirit/Relig23%

Self-efficacy (Soc)34%

SocNet: pro-abst.16%

SocNet: pro-drk.24%

Aftercare (PDA)


Depression2% Spirit/Relig

6%



SocNet: pro-drk.33%

Outpatient (PDA)


Depression11%

Spirit/Relig21%


SocNet: pro-abst.

11%

SocNet: pro-drk.16%

Aftercare (DDD)


Depression5%

Spirit/Relig9%



SocNet: pro-drk.29%

Outpatient (DDD)

DO MORE AND LESS SEVERELY ALCOHOL DEPENDENT INDIVIDUALS BENEFIT FROM AA IN THE SAME OR DIFFERENT WAYS?

effect of AA on alcohol use for AC was explained by social factors but also by S/R and through negative affect (DDD only)

Majority of effect of AA on alcohol use for OP was explained by social factors

Source: Kelly, Hoeppner, Stout, Pagano (2012) , Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous: A multiple mediator analysis. Addiction 107(2):289-99

DO MEN AND WOMEN BENEFIT FROM AA IN THE SAME WAYS?

98

DO YOUNG ADULTS BENEFIT AS MUCH AND IN THE SAME WAYS AS OLDER ADULTS


Self-effi-cacy (Soc)

32%

Religiousness7%

Depression1%SocNet: pro-abst.

7%

SocNet: pro-drk.

52%

Younger Adults (PDA)



Religiousness16%

Depression3%

SocNet: pro-abst.

25%

SocNet: pro-drk.

25%

Adults 30+ (PDA)


Self-ef-ficacy (Soc)38%

Religiousness6%Depression

3%SocNet: pro-abst.

10%

SocNet: pro-drk.

42%

Younger Adults (DDD)



Religiousness19%

Depression12%


SocNet: pro-drk.18%

Adults 30+ (DDD)

MODERATED MEDIATION FINDINGS SUGGEST

AA-derived recovery benefits differ in nature and magnitude between more severely alcohol involved/impaired and less severely alcohol involved/impaired; men and women; and, young adults and adults 30+

Differences reflect differing needs based on recovery challenges related to differing symptom profiles, degree of subjective suffering and perceived severity/threat, life-stage based recovery contexts, and gender-based social roles & drinking contexts

Similar to psychotherapy literature (Bohart & Tollman, 1999) rather than thinking about how AA or similar organizations work, better to think how individuals use or make these organizations work for them – to meet most salient needs at any given phase of recovery

MODERATED-MECHANISMS: AA EFFECTS MODERATED BY SEVERITY, GENDER, AGE…

CONCLUSIONS

“Similar to the common finding that theoretically-distinct professional interventions do not result in differential patient outcomes, AA’s effectiveness may not be due to its specific content or process. Rather, its chief strength may lie in its ability to provide free, long-term, easy access and exposure to recovery-related common therapeutic elements, the dose of which, can be adaptively self-regulated according to perceived need. “

Kelly, Magill, Stout (2009)

IF WE REALLY BELIEVED ADDICTION WAS A CHRONIC DISEASE WE WOULD…

Stop talking dirty: adopt medical lexicon that is consistent with how we describe other conditions

Formulate, implement, and evaluate various sequences of services to determine the best practices in RM

Support development and testing of long-term cost-effective RM approaches that enhance patients’ self-care and provision of long-term professional monitoring akin to other CDM (e.g., linkage to MHOs and other self-care programs)

treating addiction as a chronic disease

Documents

chronic diseases

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chronic diseasejohn

term chronic disease

cardiovascular diseases

definitions of disease

addiction medicinefaxton

vs addiction