A Transatlantic Perspective on Recovery from Addiction

Professor Keith HumphreysVeterans Affairs and Stanford University Medical Centers, Palo Alto, California

AndInstitute of Psychiatry and National Addiction Centre, King’s College London

Annual Lecture of The Welsh Council on Alcohol and Other Drugs25 June 2013

Cardiff, Wales

Scope of Talk

I. Public Policy Currents

II. Scientific Evidence

III. Transatlantic observations

Public Policy Currents

Recovering Community Support Programme

• 4-year grants given to 30 culturally, racially and geographically diverse organisations

• Each organisation developed recovery leadership capacity, advocated for better treatment, engaged in public education and provision of peer-designed recovery support services

Access to Recovery

• Treated patients in early recovery given a voucher for recovery-supportive services/products

• Voucher gave recovering people more power and choice

• Widened the number and diversity of service providers

The 2005 Recovery Summit

• Convened by the Center for Substance Abuse Treatment

• Planning committee of diverse people in recovery and their supporters

• Energizing and source of new connections

• Significant risks were taken to reach across the divides of recovery pathways

Mental Health and Addiction Benefit “Parity”

• In the U.S., most health care is paid through private insurance

• 2008 law outlaws discriminatory coverage of mental health and addictive disorders

• Recovering people inside and outside of government critical to law’s passage

Recovery as Central to Policy

• Office on Recovery Created in White House

• Unprecedented outreach to recovering community

• Initiatives to change laws that punish people in recovery

• 2010 Summit at the White House

• Think-tank co-hosted with FAVOR

Affordable Care Act

• Largest expansion of health insurance in US in over 40 years

• Full coverage of all stages of substance use disorder treatments

• Potential to cover recovery support services

• Regulatory rules extend or improve substance use treatment coverage for over 60 million people

Stirrings in Scotland

William (Bill) White at the Scotland Futures Forum

Scottish Policy Initiatives

• SACDM Methadone Project Group (2007)

• Scottish Government Road to Recovery (2008)

• Research For Recovery: A Review of the Drugs Evidence Base (2010)

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.

Other Recent UK Developments• UKDPC Statement on Recovery

• Recovery Partnership

• ACMD Committee on Recovery

• Recovery Festival

• Emergence of RCOs (e.g., Living Room)

• Methadone-Recovery Work Group

• Annual Recovery Marches

• Emergence of Recovery Coaching

Highlights of Scientific Evidence on Effectiveness and Cost-

Effectiveness

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

At 24-months, Oxford House (OH) produced 1.5 to 2 times better outcomes

0

10

20

30

40

50

60

70

80

Abstinent Employed Incarc

OH

TAU

Jason et al. (2006). Communal housing settings enhance substance abuse recovery. American J Public Health, 96, 1727-1729.

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.

Incorporating mutual-help principles in 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.

Cost offset findings in an NHS-like Health Care System

Source: Humphreys, K., & Moos, R. H. (2001). Alcoholism: Clinical and Experimental Research, 25, 711-716 and (2007). Alcoholism: Clinical &

Experimental Research, 31, 64-68.

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

1-Year Clinical Outcomes (%)

0

510

15

2025

30

35

4045

50

Abstinent No use-related problems

12-stepCog-Beh

Note: Abstinence higher in 12-step, p< .001

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.

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 (2-year total in current value $9400/£6000)

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.

Transatlantic Observations

US-UK Parallel

• No Political Party “Owns” Recovery

• The Recovery Movement works with those policymakers who will help people in recovery and their family (irrespective of party)

Two Nations Separated by Different Cultural Myths

• “Any child can grow up to be President of the United States!”

• “Let me hear your accent, and I will tell you what your father did for a living.”

Expectations of the State and Professional Helpers

• “Leave it to the professionals”

• “If you want something done right…”