KEITH HUMPHREYS

VETERANS AFFAIRS AND STANFORD UNIVERSITY MEDICAL CENTERSPALO 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?

1 A process/outcome for addicted individuals

2 A group of interventions/services

3 A set of values and ideas

4 A 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% FemaleFollow-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.

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, 711-716)

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

10

20

30

40

50

60

70

80

90

Abstinent No SA Prob Pos MH

12-stepCog-Beh

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

1-Year Treatment Costs, Inpatient Days and Outpatient Visits

0 5 10 15 20 25

OP Visits

IP Days

$1000 costCog-Beh12-step

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

0

50

100

150

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250

TxEntry 1 year 3 years 5 years

# o

f A

A m

eeti

ng

s, p

st y

r

declining AAhigh AAmedium AAlow AA

AA meeting trajectories

Kaskutas et al., ACER 2005Dependent treatment seekersn = 349

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 friendsSponsorship as a form of ministryFocus on recovery quality rather than meeting

quantityTransfer into a spiritual/religious organizationRich life outside successfully competes with

AAp.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 monthsIt varies depending on severity of problem,

social capital, other problemsIt varies based on alternative opportunitiesWhat helps the individual may disadvantage

the organization and newer membersBut 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!