KEITH HUMPHREYS VETERANS AFFAIRS AND STANFORD UNIVERSITY MEDICAL CENTERS PALO ALTO, CALIFORNIA Recovery from Addiction, Health Care Policy and Longitudinal Research

Acknowledgements Betty Ford Institute National Institute of Alcohol Abuse and Alcoholism Department of Veterans Affairs Friends, Colleagues and Research Participants in Recovery from Addiction

What is Recovery? 1A process/outcome for addicted individuals 2A group of interventions/services 3A set of values and ideas 4A cultural and political movement

A Process/Outcome for Addicted Individuals Betty Ford Institute Consensus Conference: “Recovery from substance dependence is a voluntarily maintained lifestyle characterized by sobriety, personal health and citizenship.”

A Group of Interventions/Services  Alcoholics Anonymous, LifeRing, Women for Sobriety & other peer-led mutual help organisations  Recovery Schools  Oxford House and other forms of sober residence  Recovery coaching  Faith communities centered on recovery  Recovery industries  Community support & service & living centres  Dry bars, sober cafés/clubs

Recovery* Values and Ideas Treatment is a good thing, but treatment is not recovery Addiction is real disorder worthy of health care Addiction tends to be chronic and encompassing There is hope for addicted people Addicted people have strengths, including the ability to become responsible managers of their condition *Not unique either to recovering people or titular recovery services

Recovery as a Cultural/Political Movement

Health Care Policy Currents Recovery support services growing rapidly but small in absolute size Affordable Care Act and Parity Legislation allowing expansion of billing for such services SAMHSA advocating for SA/MH merged definition More broadly, political zeitgeist is away from stigmatization, endless punishment This presentation was prepared in June...apologies if the SCOTUS has since ruined this slide!

Recovery Research Opportunities The movement, its ideas and values are a rich subject for ethnographic research and sociological analysis History of the movement and its leaders worthy of serious study Narrative/phenomenological research on identity change has a strong base upon which to build Quantitative, longitudinal research can exploit different, but equally important opportunities

What Do We Know? Oxford Houses and 12-step facilitation interventions (AA/NA/CA) are effective at reducing AOD consumption, improving psychosocial outcomes

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

At 24-months, Oxford House (OH) produced 1.5 to 2 times better outcomes Jason et al. (2006). Communal housing settings enhance substance abuse recovery. American J Public Health, 96,

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,

What Do We Know? Oxford Houses and 12-step facilitation interventions (AA/NA/CA) are effective at reducing AOD consumption, improving psychosocial outcomes To the limits of widely used statistics, naturalistic studies of AA/NA show it is broadly beneficial in years 0-3

Example study of two groups of matched patients (Humphreys & Moos, 2001, ACER, 25, ) 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

1-Year Clinical Outcomes (%) Note: Abstinence higher in 12-step, p<.001

1-Year Treatment Costs, Inpatient Days and Outpatient Visits Note: All differences significant at p <.001

What Do We Know? Oxford Houses and 12-step facilitation interventions (AA/NA/CA) are effective at reducing AOD consumption, improving psychosocial outcomes To the limits of widely used statistics, naturalistic studies of AA/NA show it is broadly beneficial in years 0-3 There is clearly a market for other forms of recovery- oriented services

What Don’t We Know

What we need to know in two areas What we need to know about recovery mutual help organizations* What we need to know about most other sorts of recovery intervention *Restricted to 12-step oriented groups, others are underresearched

Addictions are Analogous to Cancers in Some Ways But Cancer researchers/clinicians can answer two critical policy and patient questions that addiction specialists can’t (1) What is my risk for recurrence after different periods of abstinence? (2) When is the time for safe stepping down after high intensity care followed by extensive care followed by monitoring?

Styles of Post-Meeting Going Among Long-term Recovering People Network of recovering friends Sponsorship as a form of ministry Focus on recovery quality rather than meeting quantity Transfer into a spiritual/religious organization Rich life outside successfully competes with AA p.s. Officially this doesn’t happen, but everyone knows it does

But When is it Safe to Step Down, and for Whom? We don’t know exactly (kind of data we need) It’s a number of years rather than months It varies depending on severity of problem, social capital, other problems It varies based on alternative opportunities What helps the individual may disadvantage the organization and newer members But the point is, that contrary to what one hears, it happens

Basic unanswered questions about other recovery-oriented services Do recovery schools work? Do recovery business work? Do recovering community centers work? Do recovery coaches work? Etc.

Basic unanswered questions about other recovery-oriented services Do recovery schools work? Do recovery business work? Do recovering community centers work? Do recovery coaches work? Etc. Innovation is exciting and welcome, and we can’t have evidence prior to practice. But now that we have new practices, we have the responsibility to evaluate them in prospective outcome studies

An Important Distinction Regarding Evaluation of New Forms of Service A common clinical standard is that to be accepted as an innovation, a treatment must prove better on average than current practice But the population standard is (a) Does someone want it? And (b) Is it “good enough”? Examples: Women-only services, faith-based services

Thank you for your attention!