Commissioning Mutual Aid Facilitation: Obstacles and Opportunities Tony Mercer Public Health England 29th April 2014

Mutual aid groups in West Midlands   AA NA CA Smart MAP Birmingham 52 20 11 2 Coventry 14 6 1 Dudley 5 3 Herefordshire 15 Sandwell Shropshire 25 Solihull 4 Staffordshire 21 Stoke Telford & Wrekin Walsall Warwickshire 16 Wolverhampton Worcestershire West Mids Total 175

Mutual aid groups in East Midlands   AA NA CA Smart Derby 10 5 Derbyshire 15 3 Leicester 12 Leicestershire/Rutland 17 2 Lincolnshire 34 Nottingham 30 9 Nottinghamshire 31 East Mids Total 149 26 4

Opportunities Public health perspective PHE toolkit Evidence base Obstacles Organisational change Structural obstacles Ideological obstacles

Organisational change Duties and responsibilities People Money

Structural obstacles Definitions – mutual aid, peer support and recovery community organisations Inter-agency joint working Key-working - how long and how often?

Ideological obstacles Its “religious”

ACMD Recovery Standing Committee “What recovery outcomes does the evidence tell us we can expect?”   “There is emerging evidence from a meta-analysis that a close match between personal beliefs and the choice of mutual aid group actually attended improves outcomes and that non-12-step groups are probably as effective as 12- step groups.” Atkins & Hawdon (2007) Religiosity and participation in mutual-aid support groups for addiction

ACMD Recovery Standing Committee “What recovery outcomes does the evidence tell us we can expect?” Atkins & Hawdon (2007) Religiosity and participation in mutual-aid support groups for addiction the effect of different recruitment strategies interclass correlations per primary recovery groups found that they were not homogeneous no direct measurement of the degree of the “religiosity” or “spirituality” of different groups was made despite their being substantial heterogeneity among groups

ACMD Recovery Standing Committee “What recovery outcomes does the evidence tell us we can expect?” The association between 12-step mutual aid affiliation and good outcomes is strongest among people who are younger, white, less educated, unstably employed, less religious, and less interpersonally skilled Timko, DeBenedetti & Billow (2006) Intensive referral to 12-step self-help groups and 6-month substance use disorder outcomes

Kelly & White (2012) Broadening the base of addiction recovery mutual aid   In the most recent SMART participant survey (N=513) 60.7% of members reported believing in some kind of God or Higher Power 85.2% reported attending AA or other 12-step organizations in addition to SMART

Public health perspective 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 Social relationships: Overall findings from this meta-analysis Social relationships: High vs. low social support contrasted Social relationships: Complex measures of social integration Smoking <15 cigarettes daily Smoking cessation: Cease vs. continue in patients with CHD Alcohol consumption: Abstinence vs. excessive drinking Flu vaccine: Pneumococcal vaccination in adults Cardiac rehabilitation (exercise) for patients with CHD Physical activity (controlling for adiposty) BMI: Lean vs. obese Social relationships have as great an impact on health outcomes as smoking cessation, and more than physical activity and issues to address obesity (Holt-Lunstad et al 2010) Drug treatment for hypertension in populations > 59 years Air pollution: low vs. high UNCLASSIFIED

Public health perspective 5 ways to well-being important to all. May be especially lacking in drug users and needing attention during recovery, to support recovery. Mutual aid can contribute to most of the 5 ways – even ‘be active’ if people walk or cycle to meetings!

Public health perspective Psychotherapeutic Social Networks Bio Medical

Public health perspective Asset Based Commissioning – look what's in the fridge before going to the supermarket

PHE toolkit A briefing on the evidence-based drug and alcohol treatment guidance recommendations on mutual aid Brings together existing findings and recommendations from: •NICE Quality Standards and Clinical Guidelines •RODT: Medications in Recovery •ACMD: Recovery Standing Committee’s 2nd report on recovery outcomes

Mutual aid self-assessment tool PHE toolkit Mutual aid self-assessment tool Availability Promoting mutual aid Leadership and workforce Facilitation Local strategic planning and monitoring

PHE toolkit Facilitating access to mutual aid: three essential stages for helping clients access appropriate mutual aid support

PHE toolkit Improving access to mutual aid: a brief guide for commissioners Local vision Self-assessment Local action plan/steering group Service specifications NDTMS Engaging with Mutual Aid Oct 2013

PHE toolkit Improving access to mutual aid: a brief guide for alcohol and drug treatment service managers Develop links with local groups/reps Workforce knowledge and skills Literature and promotion FAMA/key-working/supervision Care-planning documentation Engaging with Mutual Aid Oct 2013

Evidence base If mutual aid works………. it will improve performance (more successful completions/less representations) there's an ethical case for doing it

QS23 Quality standard for drug use disorders (2012) Quality statement 7: Recovery and reintegration   People in drug treatment are offered support to access services that promote recovery and reintegration including housing, education, employment, personal finance, healthcare and mutual aid.

6/7 studies included focussed on 12 step mutual aid groups NICE Clinical Guidelines CG51 (2007) psychosocial interventions for drug misuse 23 studies identified 16 studies excluded 6/7 studies included focussed on 12 step mutual aid groups 2 x RCTs - McAuliffe (1990) and Timko et al.(2006) 1 x RCT sub-analysis - Weiss et al. (2005) 2 x cohort studies - Moos et al. (1999) and Ethridge et al. (1999) 1 x prospective longitudinal study - Fiorentine & Hillhouse (2000) 1 x case series - Toumbourou et al. (2002)

NICE Clinical Guidelines CG51 (2007) psychosocial interventions for drug misuse Clinical summary   There is limited but consistent evidence from these studies that 12-step attendance is associated with abstinence from illicit drugs and alcohol, and fewer drug and alcohol problems. Furthermore, involvement in such programmes can be improved by interventions from healthcare professionals to encourage regular attendance and active participation in such groups.

Clinical practice recommendations NICE Clinical Guidelines CG51 (2007) psychosocial interventions for drug misuse Clinical practice recommendations Staff should routinely provide people who misuse drugs with information about self-help groups. These groups should normally be based on 12-step principles; for example, Narcotics Anonymous and Cocaine Anonymous. If a person who misuses drugs has expressed an interest in attending a 12-step self-help group, staff should consider facilitating the person’s initial contact with the group, for example by making the appointment, arranging transport, accompanying him or her to the first session and dealing with any concerns.

NICE Clinical Guidelines CG115 (2011) Diagnosing, assessing and managing harmful drinking and alcohol dependence For all people seeking help for alcohol misuse: •give information on the value and availability of community support networks and self-help groups (eg, AA or SMART Recovery) •help them to participate in community support networks and self-help groups by encouraging them to go to meetings and arranging support so that they can attend

NICE Clinical Guidelines CG115 (2011) Diagnosing, assessing and managing harmful drinking and alcohol dependence TSF v CBT - Easton (2007) TSF v MET and CBT - MATCH (1997) TSF v coping skills - Walitzer (2009) TSF v couples therapy and psycho-educational intervention - Falsstewart (2005), Falsstewart (2006)   Standard TSF v intensive TSF – Timko (2007) Directive TSF v motivational TSF and coping skills – Walitzer (2009)

NICE Clinical Guidelines CG115 (2011) Diagnosing, assessing and managing harmful drinking and alcohol dependence TSF was significantly better than other active interventions in reducing the amount of alcohol consumed when assessed at 6- month follow-up Those receiving TSF were more likely to be retained at 9-month follow-up Intensive TSF was significantly more effective than standard TSF in maintaining abstinence at 12-month follow-up Directive TSF was more effective at maintaining abstinence than motivational TSF up to 12-month follow-up

ACMD Recovery Standing Committee “What recovery outcomes does the evidence tell us we can expect?” 9. The roles of recovery community organisations and mutual aid, including Alcoholics Anonymous, Narcotics Anonymous and SMART Recovery, are to be welcomed and supported as evidence indicates they play a valuable role in recovery.

ACMD Recovery Standing Committee “What recovery outcomes does the evidence tell us we can expect?” A range of recovery outcomes and sustained recovery are more likely to be achieved if people engage in mutual aid (AA) Fiorentine (1999), Kelly, Hoeppner, Stout & Pagano (2012)  Mutual aid (AA) participants who become actively involved in helping others, for example as a sponsor, are more likely to do well Fiorentine, (1999), Pagano, Friend, Tonigan, & Stout, (2004)  Having a sponsor early (AA) was beneficial and predicted increased abstinence from alcohol, cannabis and cocaine Tonigan & Rice (2010)  

ACMD Recovery Standing Committee “What recovery outcomes does the evidence tell us we can expect?” Being a sponsor (NA/AA) over a one-year period, was strongly associated with substantial improvements in sustained abstinence rates for injecting drug users Crape, Latkin, Laris & Knowlton (2002) “There is emerging evidence on other forms of mutual aid, for example, SMART Recovery”

Opportunities Public health perspective PHE toolkit Evidence base Obstacles Organisational change Structural obstacles Ideological obstacles