Peer‐based Addiction Recovery Support: History, Theory, Practice, and Scientific Evaluation
Peer Power and Recovery from Addiction
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Transcript of Peer Power and Recovery from Addiction
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Peer Power and Recovery from Addiction
Keith HumphreysProfessor of Psychiatry
Veterans Affairs and Stanford University Medical CentersPalo Alto, California
Presented at the European Federation of Therapeutic CommunitiesOxford, UK
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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
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Mutual Help Organizations and Therapeutic Communities: Shared Assumptions
• The Power of Peers
• The Conceptualization of Addiction
• The Concept of Recovery
• The Emphasis on Long-Term Intervention
• Optimism about Addicted People
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Estimated substance-related self-help/mutual aid organizations (12 step in red)
Estimated Number of Groups Worldwide
Alcoholics Anonymous 101,000Al-Anon 30,000Narcotics Anonymous 21,000Cocaine Anonymous 2,000LifeRing/Secular Organization for Sobriety 1,800Adult Children of Alcoholics 1,500Marijuana Anonymous 1,000SMART Recovery 1,000Moderation Management 500Women for Sobriety 350
Sources: 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.
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Note: NA is for all drugs not just narcotics
12-step groups have established themselvesin the once-impenetrable Middle East
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Selected data on clinical and cost-effectiveness
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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% Female
• Follow-ups every 6 months for 2 years, 90% of subjects re-contacted
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At 24-months, Oxford House (OH) produced 1.5 to 2 times better outcomes
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Abstinent Employed Incarc
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Jason et al. (2006). Communal housing settings enhance substance abuse recovery. American J Public Health, 96, 1727-1729.
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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.
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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.
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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.
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Alcohol-related outcomes of 201 individuals initially selecting AA (n = 135) or outpatient treatment (n = 66)
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Total alcohol-related health care costs over three years by comparable alcoholic individuals who initially chose Alcoholics Anonymous or professional outpatient treatment
AA group Outpatient group
(n=135) (n=66) F
mean SD mean SD (df=1,199)
Per person costs
Year 1 $1,115 $2,386 $3,129 $4,355
Years 2 and 3 $1,136 $4,062 $948 $2,852
Total $2,251 $5,075 $4,077 $5, 371 5.52*
Note *p<.05
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Replication of cost offset findings in Department of Veterans Affairs Sample
Source: This study appeared in Alcoholism: Clinical and Experimental Research, 25, 711-716.
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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 cognitive-behavioral principles and placed little emphasis on self-help activities
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Self-help group participation at 1-year follow-up was higher after self-help 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
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1-Year Clinical Outcomes (%)
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Abstinent No SA Prob Pos MH
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Note: Abstinence higher in 12-step, p< .001
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1-Year Treatment Costs, Inpatient Days and Outpatient visits
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OP Visits
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$1000 costCog-Beh12-step
Note: All differences significant at p <.001
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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)
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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.
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What mediates these benefits?
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B “mediates” the relationship between A and C
A>>>>>>>>>B>>>>>>>>C
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Note
All paths significant at p<.05. Goodness of Fit Index = .950.
Self-Help Group
Involvement
Reduced Substance
Use
Active Coping
GeneralFriendship Quality
Friends’ SupportFor Abstinence
Structural equation modeling results from over 2,000 patients assessed at intake, 1-year, 2-year
Motivation to change
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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
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12-step vs. non-12 step based friendship networks of 1,932 treated
SUD patients
01020
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%friends in 12S %Abstainers
12-stepNon
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.
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Summary of What We Know
• 12-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.
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Implications for TCs
• Basic 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
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Thank you for your attention!