1. The Evidence Base on Peer- Managed Addiction Recovery Organisations Professor Keith Humphreys Veterans Affairs and Stanford University Medical Centers, Palo Alto, California And Institute of Psychiatry and National Addiction Centre, Kings College London Presented 8 June 2012 at NTA Conference, Birmingham, UK

2. Overview Definition and Scope of peer-led recovery organisations Effectiveness and Cost-effectiveness of 12-step based organisations Clinical and Policy implications

3. Definition of Self-Help (aka Mutual Help) Recovery Organisations Essential Peer-directed, self-governing Value experiential knowledge and reciprocal helping Free or nominal cost only Some Provide a structured program and philosophy Have an abstinence orientation Attendance by addicted person/Attendance alone Spiritual or Religious Content Have a Residential Structure

4. Addiction self-help organizations are an international phenomenon Austria: Blue Cross France: Vie Libre Hong Kong: SAARDA Japan: Danshukai Poland: Abstainers Clubs Sweden: The Links Iran: Narcotics Anonymous

5. Note: NA is for all drugs not just narcotics 12-step groups have established themselves in the once-impenetrable Middle East

7. Help-seeking visits in U.S. for psychiatric and substance abuse problems by sector

8. But do they work? Popularity does not equal effectiveness Most forms of recovery-oriented intervention have not been well-evaluated However, a sizable evidence base has accumulated regarding 12-step oriented interventions

9. Selected data on clinical and cost-effectiveness* *Summarizing the data where they are at present

10. Clinical trial of Oxford House Oxford House is a democratic, self- supporting, peer-managed residential setting 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

11. 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, 1727-1729.

12. 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.

13. 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.

14. 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 Source: see Humphreys, K. (2004). Circles of Recovery: Self-help organisations for addictions. Cambridge University Press, for a review.

15. Studies of cost consequences

16. Incorporating mutual-help principles in to treatment increases cost-effectiveness Sample:249 low-income alcohol-dependent patients Design:Random assignment to usual care or experimental unit with 50% less staff and higher expectation of patient self and mutual help Results: One-year outcomes comparable except for better social adjustment among experimental patients Source: Galanter, M. et al. (1987). Institutional self-help therapy for alcoholism: Clinical outcome. Alcoholism: Clinical & Experimental Resesarch, 11, 424-429.

17. Total alcohol-related health care costs over three years by comparable alcoholic individuals who initially chose Alcoholics Anonymous or professional outpatient treatment AA groupOutpatient group (n=135)(n=66)F meanmean (df=1,199) Per person costs Year 1 £1,100 £ 3,100 Years 2 and 3 £1,100 £ 1,000 Total £2,200 £ 4,100 5.52* Note *p<.05 Humphreys, K., & Moos, R. (1996). Reduced substance abuse-related health care costs among voluntary participants in Alcoholics Anonymous. Psychiatric Services, 47, 709-713. Inflated to 2012 prices and converted to approximate pounds sterling.

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

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

20. 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

21. 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

22. 1-Year Clinical Outcomes (%) Note: Abstinence higher in 12-step, p<.001

23. Treatment programs that strongly promote recovery mutual help involvement have lower 1-Year Costs: Study of over 1,700 substance-dependent veterans. Humphreys, K., & Moos, R. H. (2001). Can encouraging substance abuse inpatients to participate in self-help groups reduce demand for health care?: A quasi-experimental study. Alcoholism: Clinical and Experimental Research, 25, 711-716.

24. 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) Humphreys, K., & Moos, R. (2007). Two year clinical and cost offset outcomes of facilitating 12-step self-help group participation. Alcoholism: Clinical & Experimental Research, 31, 64-68.

25. Clinical and Policy Implications

26. 48% 18% 45% 48% 60% 36% 66% 58% 0 25 50 75 100 attended meetingshad sponsor read 12-step literature had a friend who Attends A A/NA 12-step self-help group involvement Cog Beh 12-Step % 12-step group involvement of 2,045 substance-dependent veterans after 12-step or cognitive-behavioral treatment Note: Involvement was measured one year after discharge by patient reports of activities in the past 3 months. Data in this table were drawn from Humphreys et al. (1999), Alcoholism: Clinical and Experimental Research, 23, 558-563.

27. We do that already: Normal referral processes are ineffective Sample:20 alcohol outpatients Design:Outpatients randomly assigned to standard 12-step self-help group referral (list of meetings and therapist encouragement to attend) or intensive referral (in-session phone call to active 12-step group member) Results: Attendance rate after intensive referral: 100% Attendance rate after standard referral: 0% Source:Sisson, P.W., & Mallams, J.H. (1981). The use of systematic encouragement and community access procedures to increase attendance at AA meetings. Am J Drug Alc Abuse, 8, 371-376.

28. Peer-based referral can be beneficial in non-specialty settings ControlBI BI+Peer 6-month abstinence 36%51%64% TX/AA Initiation 9%15%49% Source: Study by Rick Blondell, M.D. of 140 patients hospitalized For alcohol-related injuries, J Fam Practice, 50

29. 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.

30. Visits to self-help groups in Oakland and Los Angeles in 3 months of Pro-Self-Help Media vs. in same 3 months of prior year Humphreys, K., Macus, S., Stewart, E., & Oliva, E. (2004). Expanding self-help group participation in culturally diverse urban areas: Media approaches to leveraging referent power. Journal of Community Psychology, 32, 413-424.

31. Conclusions 12-step group participation significantly reduces substance use and health care costs. Benefits of 12-step groups mediated both by psychological and social changes. Other recovery mutual help organisations should be more greatly studied. Applying these findings in treatment settings should improve outcomes and reduce costs. A modest investment in self-help supportive infrastructure would likely more than pay for itself and yield significant public health gains.