Summary& Below&please&provide&a&brief&summary&of&this&resource.&If&an&abstract&is&available,&feel&free&to&copy&and&paste&it&here.&

!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!P.!O.!Box!6448!!Reno,!NV!89513!•!Phone:!760:815:3515!•[email protected]! ! Title& Below&please&list&the&title&of&this&resource.&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ! Where!Does!The!Data!Direct!Us?:!Addiction!Recovery!Management!and!the!Role!of!12:Step!Mutual!Help! Resources! ! Author& Below&please&list&the&author(s)&of&this&resource." ! John!F.!Kelly,!Ph.!D.!! ! Citation& Below&please&cite&this&resource&in&APA&style.&For&guidance&on&citation&format,&please&visit& http://owl.english.purdue.edu/owl/resource/560/01/& ! John!F.!Kelly,!Ph.!D.!(2012).!Where"Does"The"Data"Direct"Us?:"Addiction"Recovery"Management"and"the"Role"of" 12?Step"Mutual"Help"Resources."[PowerPoint!Slides].!Proceedings!from!the!3rd_{!National!Collegiate!Recovery!}

Conference:!Understanding!and!Responding!to!Young!Adult!Addiction!and!Recovery:!Kennesaw,!Georgia.! ! Summary& Below&please&provide&a&brief&summary&of&this&resource.&If&an&abstract&is&available,&feel&free&to&copy&and&paste&it&here.& ! In!this!power!point!presentation!Dr.!Kelly,!provides!the!background!and!context!for!addiction!recovery! management,!the!rationale!and!conceptualization!of!addiction!recovery!management,!discusses!mutual:help! organizations,!and!elaborates!on!the!role!of!mutual:help!organizations!in!recovery!for!young!people.! ! Categorization& Below,&please&select&the&key&words&that&describe&how&this&resource&applies&to&our&research&on&thriving&collegiate& recovery.&If&the&keywords&below&do&not&apply,&please&select&‘other’&and&list&the&appropriate&key&word.& " X"Success"in"Established"Collegiate"Recovery"Programs" X"Success"in"Established"Recovery?Oriented"Systems"of"Care" "Asset?Based"Research/Methodology" X"General"Recovery"Assets" X"Interpersonal"Assets" X"Intrapersonal"Assets" X"Community?Based"Assets" X"History"of"Recovery" "Other:"______________________________________"

W

HERE

DOES

THE

DATA

DIRECT

US

?

A

DDICTION

RECOVERY

MANAGEMENT

AND

THE

ROLE

OF

12-

STEP

MUTUAL

HELP

RESOURCES

John F. Kelly, Ph.D.

Associate Professor in Psychiatry

Harvard Medical School

Program Director Addiction Recovery Management Service Associate Director MGH Center for Addiction Medicine

“Mankind, ever in pursuit of pleasure,

have reluctantly admitted into the

catalogue of their diseases, those evils

which were the immediate offspring of

their luxuries”

-

Thomas Trotter (1798). An essay, medical, philosophical and chemical on the effects of alcohol on the human body

O

VERVIEW



Background and Context



Rationale and Conceptualization: Addiction Recovery

Management



Mutual-help organizations



The role of mutual-help organizations in recovery

D

RUG

AND

A

LCOHOL

C

ONCERNS

• #1 public health problem (Institute for Health

Policy, 2001; CASA, 2011)

• Of all disease, disability, and deaths due to all psych conditions, alcohol use disorder alone = 36%

Public

health

• $500 billion in US each year (lost productivity, criminal justice, medical costs)

• Excessive alcohol consumption costs society $2 per drink (CDC, 2011)

Financial

• SUD leading cause of mortality - alcohol leading risk factor among males 15-59 worldwide

• Opiate overdose – 2nd _{leading cause of}

accidental death nationwide; 1st _{in 17 states}

Mortality

• Onset of long-term problems occur during adolescence/young adulthood

• 90% adults with dependence start using before age 18

• 50% of adults start using before age 15

E

CONOMIC

COSTS

TO

SOCIETY

Bouchery et al. (2011), CDC (2012), US Department of Justice (2011)

$0 $50 $100 $150 $200 $250 $300 $350 $400 $450 Alcohol and

Illicit drugs Diabetes Obesity Smoking Heart disease

% U

SING

PRIOR

TO

AGE

15

0% 5% 10% 15% 20% 25% 30% 35% 1934-1944 1945-1955 1956-1960 1961-1965 1966-1970 1971-1975 1976-1980 1981-1985 1986-1990 % u si n g Alcohol use Marijuana Cocaine Hallucinogens

%

MEETING

DSM-III-R

LIFETIME

ALCOHOL

DEPENDENCE

CRITERIA

Adapted from: Rice, J. P., Neuman, R. J., Saccone, N. L., Corbett, J., Rochberg, N., Hesselbrock, V., & ... Reich, T. (2003). Alcoholism: Clinical And Experimental Research, 27(1), 93-99.

0% 5% 10% 15% 20% 25% 30% 35% 1910-1929 1930-1939 1940-1949 1950-1959 1960-1979 Male (n=509) Female (n=545) Birth Cohort

S

UBSTANCE

U

SE

D

ISORDERS

(SUD)

IN

THE

P

AST

S

UBSTANCE

U

SE

AND

P

ROBLEM

O

NSET

AND

O

FFSET

NSDUH and Dennis & Scott 0 10 20 30 40 50 60 70 80 90 100 12-13 14-15 16-17 18-20 21-29 30-34 35-49 50-64 65+

No Alcohol or Drug Use Light Alcohol Use Only Any Infrequent Drug Use

Regular AOD Use Abuse

Dependence

National Survey on Drug Use and Health (NSDUH) Age Groups

W

HY

DOES

SUD

ONSET

IN

YOUNG

PEOPLE

?

D

EVELOPMENTAL

C

ONSIDERATIONS

& R

ISKS

 Desire “forbidden (fermented) fruit” associated with “being grown up”  New social freedoms with age of majority (i.e., 18 yrs = right to vote,

serve on jury/military/marry) independent living (e.g., college), employment/$$$

 Exhilarating - activating abrupt cognitive shift in perceived control

and self-determination, but objective psychobiological reality =

continues to be gradual developmental changes - impulse control, self-regulation, risk appraisal (Giedd et al, 1999).

 Lower sensitivity to (psychomotor) negative impairments than adults  So, desire for “forbidden fruit” & self-expression coupled with

incongruency between subjective perceptions and objective reality creates new risks & challenges particularly regarding alcohol/drugs

E

MERGING

A

DULT

C

LINICAL

D

IFFERENCES

• Compared to adolescents and/or older adults, young adults:

• Have highest rates of co-occurring psychiatric problems (Chan,

Dennis et al, 2008)

• Rates of SUD that are 2-3x higher in this age-group than

either adolescents or older adults (SAMHSA, 2007)

• Are least likely to follow through with continuing care (Shin,

Lundgren et al, 2007).

• Have an earlier onset of alcohol/drug use, but report lower

readiness for change (Sinha, et al, 2003).

• More likely to relapse in social contexts (Brown et al, 1993)

O

VERVIEW



Background and Context



Rationale and Conceptualization: Addiction Recovery

Management



Mutual-help organizations



The role of mutual-help organizations in recovery

R

ATIONALE FOR

L

ONG

-

TERM

R

ECOVERY MANAGEMENT



Minority seek addiction care (SAMHSA, 2010;

Dawson et al, 2005); tx-seekers typically more

severe/complex



Chronic relapsing nature of addiction

requires a continuing care approach for those who

seek care, akin to management of other chronic

illnesses (e.g., diabetes and hypertension

(McLellan et al, 2000)



As in hypertension/diabetes, regular check-ups,

and self/medical monitoring prevent crises

(myocardial infarct; renal failure) and reduce

expensive medical care (hospitalization)

W

HY

ARE

RECOVERY

SUPPORT

SERVICES

IMPORTANT

?



Among treatment seekers

psychiatric, medical, legal,

education, employment, and family

problems

common

(Davidson et al, 2010)

–

impede effectiveness of

purely addiction-focused clinical efforts



Adding more addiction focused sessions

within a brief

time

period does not improve outcomes (e.g., Project

MATCH, 1997;; CYT;; Dennis et al, 2004)…



…but, adding recovery support services and

community mutual-help facilitation can enhance and

sustain tx gains (Boisvert et al, 2008; Kelly and

Yeterian, 2011; McLellan et al, 1998; Milby et al, 1996;

Rowe et al, 2007) adding to individuals’ “

recovery

capital

”

C

HRONIC NATURE OF SUBSTANCE DEPENDENCE MAKES IT WELL

-SUITED TO ONGOING

R

ECOVERY

M

ANAGEMENT

(RM)

APPROACHES

…

 Addiction talked as chronic but still

treated as acute condition:

 Serial episodes of self-contained and

unlinked intervention

 Implicit expectation that a lifelong cure

will occur following a single episode of “rehab”

 Continuing care (“aftercare”) as

afterthought

 Recovery management is a philosophy of

organizing addiction treatment and

recovery support services to enhance early pre-recovery engagement, recovery

initiation, long-term recovery

S

UPPORT

S

ERVICES

IN

THE

T

REATMENT

B

I

-

AXIAL

MODEL

OF

A

DDICTION

Addiction severity

Substance-related problems

(physical and mental health; housing; social and family relations; education and

employment)

Kelly et al, (under review) Reciprocal: Increasing severity leads

to more problems and more problems perpetuates continued use

B

I

-

AXIAL

MODEL

OF

RECOVERY

Addiction Remission

Recovery Capital

(physical and mental health; housing; social and family relations; education and

employment)

Kelly et al, (under review) Reciprocal: Increasing duration of remission leads

to greater recovery capital BUT ALSO greater recovery capital perpetuates continued remission

S

TRESS AND

L

IFE

S

ATISFACTION AS A

F

UNCTION OF

L

ENGTH OF

R

ECOVERY

(N = 354)

RECOVERY STAGE 3+ years 18 to 36 mos Six to 18 mos >6 months M ea n (s ca le ra ng e = 0 to 1 0) 8.5 8.0 7.5 7.0 6.5 6.0 5.5 5.0 Overall life satisfaction Stress rating pst yr

W

HAT

ARE

R

ECOVERY

SUPPORT

SERVICES

?



Residential recovery homes (e.g., Oxford Houses)



Recovery community centers (RCCs)



Peer-based Recovery support



Education-based recovery support: high school

and college based recovery support for young

people

H

OW MIGHT

R

ECOVERY

S

UPPORT

S

ERVICES AID

RECOVERY

?

I

NTRA

-I

NDIVIDUAL

M

EDIATORS

Residential recovery homes Recovery community centers Peer-based recovery support Education-based recovery support Mutual-help organizations Motivation Self-efficacy Coping Self-esteem/respect Hope/future orientation Spirituality/purpose/meani ng Recovery maintenance

R

ECOVERY CONTEXTS

: E

DUCATION

B

ASED

R

ECOVERY SUPPORTS

College education trumped money and social prestige as the pathway to health and happiness (Vaillant, 2011)

Despite big differences between core city sample and Harvard sample in

parental social class, college-tested intelligence, current income and job status,

health decline of inner-city men who obtained a college education was same as Harvard sample Education represents important recovery

A

SSOCIATION

OF

RECOVERY

SCHOOLS

 Despite education being important to long term health and

well-being, college environment is recovery unfriendly -activities organized around alcohol/parties limiting social options; not wanting to disclose recovery status.

 Collegiate Recovery Communities (CRCs) in some

colleges-safe place and sobriety-friendly network

 Founding college programs:

- Augsburg College - Texas Tech University - Rutgers (1st _{to offer an}

on-campus residence

hall for students it recovery)

 15 participating high schools  16 participating colleges

 Schools provide academic services and assistance with

recovery and continuing care, but they are not treatment centers

 No experimental/comparative effectiveness trials to estimate

T

EXAS

T

ECH

U

NIVERSITY

: S

INGLE

GROUP

P

RE

-P

OST

D

ESIGN



To enter the CRC, students need to have 1 year of

recovery, attend at least 1 12-step on campus meeting per

week, and succeed in their classes



evaluation of the program: 2004-2005, N=82, (18-53 yrs

old)



relapse rate within a semester was 4.4%; most maintained

high GPA

A

UGSBURG

C

OLLEGE

S

TEP

U

P

PROGRAM



Support groups and sobriety-specific houses



Outcomes…

Annual avg relapse rate across 13 yrs = 13%, Down to about 7% in recent yrs

R

UTGERS

R

ECOVERY

H

OUSE

DATA

2008-2011

Source: Laitman & McLaughlin (2011)

Annual avg relapse rate

across

E

DUCATIONAL

CONTEXT

RECOVERY

SUPPORT

PROGRAMS

: S

UMMARY



Programs are catching on rapidly in college

settings



Make return to college more attractive and

increases access; can have life-long ramifications



High retention, low relapse rates, and high

academic achievement



Comparative investigations lacking

–

would

inform the nature, content, and intensity of

support

O

VERVIEW



Background and Context



Rationale and Conceptualization: Addiction Recovery

Management



Mutual-help organizations



The role of mutual-help organizations in recovery

MUTUAL

-

HELP

:

IMPLICATIONS FOR ENHANCING RECOVERY AND CONTAINING COST

- 5

THINGS WE

’

VE LEARNED

:

1. Mutual-help organizations help offset burden of disease

from SUD

2. Mutual-help groups confer clinically meaningful benefits for

many different types of individuals above and beyond formal treatment services

3. Mutual-help groups work through mechanisms similar to

those operating in formal treatment

4. Mutual-help group participation can reduce healthcare

costs by reducing patients’ reliance on professional services

without any detriment to outcomes, and actually enhance outcomes

5. Empirically-supported clinical interventions (TSF) can

increase participation in mutual-help groups, reduce health care costs, and enhance outcomes

Kelly JF and Yeterian JD (In press). Empirical Awakening: The new science on mutual-help and implications for cost containment under health care reform. Substance Abuse

M

UTUAL

HELP

R

ESEARCH

- R

ECENT

H

ISTORY

 Given public health

significance, Institute of Medicine (IOM, 1990) called for AA research.

 state of science summarized

and further research opportunities outlined

(McCrady and Miller, 1993)

 Past 20 yrs significant

increase in scientific

interest and rigor focused

on AA. 0 50 100 150 200 250 300 350 400 450 1960-70 1971-80 1981-90 1991-00 2001-10 Number of Publications on AA and NA 1960-2010

F

INDINGS

FROM

META

-

ANALYSES

 Emrick et al. 1993 - 107 studies. AA attendance and involvement modest beneficial effect on drinking behavior

 Tonigan et al., 1996 - 74 studies. Examined moderators of

effectiveness (i.e. outpatient vs. inpatient; study quality)

 Studies generally, were “methodological poor” and underpowered

 Kownacki & Shadish, 1999 – 21 studies. Examined controlled trials only

- Randomization confounded with coerced status (justice system required)

- Coerced individuals fared worse than individuals in other treatment or no treatment

- Coerced individuals may have better outcomes if coerced into other kinds of treatment

- Found support for 12-step-based tx and non-coerced AA attendance

F

ERRI

, A

MATO

, D

AVOLI

(2006)

(C

OCHRANE

R

EVIEW

)

 Attempted to examine RCTs of AA or TSF  8 trials involving 3417 people were included.  Findings:

 AA may help patients to accept treatment and keep patients in

treatment more than alternative treatments

 AA had similar retention rates

 3 studies compared AA combined with other interventions

against other treatments and found few differences in the amount of drinks and percentage of drinking days

 AA found to be as effective as other comparison

F

OR

WHOM

ARE

MUTUAL

-

HELP

GROUPS

PARTICULARLY

HELPFUL

/

NOT

HELPFUL

?



Clinical concerns member-group fit with 12-step

mutual-help organizations.



1. Dual-diagnosed (DD)?



2. Non-religious people?

P

SYCHIATRIC

C

OMORBIDITY

I.



SUDs frequently co-occur

with psychiatric illnesses



Concerns about

member-group fit of co-morbid with

typical 12-step groups



Barriers

 Putative opposition to

medications

 Clinical syndromes vs. “not

D

UAL

-D

IAGNOSIS

S

UMMARY

S

HOULD

DD

PATIENTS

BE

REFERRED

TO

AA/NA?



Attendance rates may be similar and many may

benefit (e.g. PTSD)



More severely impaired (e.g., psychosis) may

have more difficulty



Attendance rates may be similar but co-morbid

may require additional/more specific support

and/or greater facilitation (e.g. severe MDD)

R

ELIGIOUSNESS

& 12-

STEP

MUTUAL

-

HELP



Concerns about quasi-religious concepts



Implications for non-religious individuals



Referral to 12-step organizations should take

into account religious background.



Practice guidelines of APA, recommend

clinicians refrain from referring nonreligious

people to 12-step.

R

ELIGIOUSNESS

& 12-

STEP

MUTUAL

-

HELP



Winzelberg & Humphreys, (1999; N=3,018 male

veterans)



“Belief in God” did not relate to attendance



People lower in recent religious practices attended less

frequently



Degree of religiosity did not affect salutary relationship

between AA/NA and substance use outcomes at 1 and

3yrs (Kelly, Stout et al, 2006; Winzelberg et al, 1999)



Project MATCH - religiousness did not interact with txs

(Connors et al.2001)



Brown, et al (2001; N= 153)

–

no relationship between

religious involvement and frequency of 12-step

attendance

R

ELIGIOSITY

S

UMMARY

& R

ECOMMENDATIONS

:



Should non-religious patients be referred to 12-Step

mutual-help groups?

 Little evidence to suggest not

 Educate about “spirituality” vs. “religion” and socially mediated

benefits (e.g., Litt et al, 2009; Kelly et al, 2011)

 50% of original membership atheist/agnostic (AA, 2001)  Consider non-12-step: SMART Recovery; LifeRing; SOS

W

OMEN

AND

MUTUAL

-

HELP

I



Women make up about one-third of tx & AA population



Concern over fit of women in 12-step organizations



Emphasis on “powerlessness”



Minority status of women in 12-step groups. -

W

OMEN

AND

MUTUAL

-

HELP

II



Women appear to attend and benefit as much

as men (and get more involved)



Unclear whether women-only meetings

(common in AA) benefit women more



Unclear whether other women-specific

organizations (Women for Sobriety) may

improve outcomes for women

Given health care burden of

SUD, can Mutual-help group

participation reduce

healthcare costs by reducing

patients’ reliance on

professional services and

produce better outcomes?

C

OST

-

EFFECTIVENESS

(1)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Abstinent No SA-related problems No psychological problems No psychiatric problems

CBT TSF

0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0

12-step attendance Inpatient days Outpatient visits

CBT TSF

C

OST

-

EFFECTIVENESS

(2)

C

OST

-

EFFECTIVENESS

II (1) 2YR F

OLLOW

-UP

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% Abstinent No SA-related

problems No psychologicalproblems No psychiatricproblems

CBT TSF

C

OST

-

EFFECTIVENESS

II (2) 2YR F

OLLOW

-UP

0.0 2.0 4.0 6.0 8.0 10.0 12.0

12-step attendance Inpatient days Outpatient visits

CBT TSF

$12,129.00

$7,400.00

CBT TSF

Cost per patient over 1 year *

Cost per patient over 1 year *

H

EALTH

C

ARE COST OFFSET POTENTIAL OF

MHG

S

(1)

CBT VS 12-STEP RESIDENTIAL TREATMENT

CBT Resulted in $4,729

greater costs per patient with sig. worse outcomes

$5,735.00

$2,440.00

CBT TSF

Cost per patient over 1-2 year

Cost per patient

CBT Resulted in $3,295

greater costs per patient with sig. worse

outcomes in Yr 2 Follow up

SOURCE: HUMPHREYS & MOOS, 2001; 2007

Compared to CBT-treated patients, 12-step treated patients more likely to be in recovery, at a $8,000 lower cost per pt over 2 yrs

How do Mutual help

organizations like AA help

individuals maintain recovery

over time?

What can such data tell us more

broadly about recovery

Social Psych Neuro-biology RELAPSE Cue Induced Stress Induced Drug Induced

How might MHGs like AA reduce relapse risk and sustain the recovery process?

AA-related social network changes may help avoid cues, reduce and tolerate distress, and maintain

abstinence minimizing drug-induced

relapse risks AA

(9-mo) Self-efficacy Negative Affect Baseline (BL) Covariates Age Race Sex Marital Status Employment Status Prior Alcohol Treatment MATCH Treatment group MATCH study site

Alcohol Outcomes (PDA/DDD)

(15-mo) Alcohol Outcomes

(PDA or DDD) (3-mo) AA attendance (BL) Self-efficacy Negative Affect (9-mo) Self-efficacy Positive Social (BL) Self-efficacy Positive Social (9-mo) Religious/Spiritual Practices (BL) Religious/Spiritual Practices (9-mo) Depression (BL) Depression

(9-mo) Social Network

“pro-­abstinence”

(BL) Social Network

“pro-­abstinence”

(9-mo) Social Network

pro-­drinking”

(BL) Social Network

“pro-­drinking”

Source: Kelly, Hoeppner, Stout, Pagano (2012). Determining the relative influence of the mechanisms of behavior change within Alcoholics Anonymous. Addiction, 107, 2, 289-299.

RELATIVEUNIQUE CONTRIBUTIONOFEACHMEDIATORIN EXPLAININGAA’SEFFECTSONALCOHOL OUTCOMES Self-efficacy (NA) 5% Depression 3% Spirit/Relig 23% Self-efficacy (Soc) 34% SocNet: pro-abst. 16% SocNet: pro-drk. 24% Aftercare (PDA) Self-efficacy (NA) 1% Depression 2% Spirit/Relig 6% Self-efficacy (Soc) 27% SocNet: pro-abst. 31% SocNet: pro-drk. 33% Outpatient (PDA) Self-efficacy (NA) 20% Depression 11% Spirit/Relig 21% Self-efficacy (Soc) 21% SocNet: pro-abst. 11% SocNet: pro-drk. 16% Aftercare (DDD) Self-efficacy (NA) 1% Depression 5% Spirit/Relig 9% Self-efficacy (Soc) 39% SocNet: pro-abst. 17% SocNet: pro-drk. 29% Outpatient (DDD) 51

Source: Kelly, JF, Hoeppner, B. Stout, RL, Pagano, M. (2011) Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous,

RELATIVEUNIQUE CONTRIBUTIONOFEACHMEDIATORIN EXPLAININGAA’SEFFECTSONALCOHOL OUTCOMES Self-efficacy (NA) 5% Depression 3% Spirit/Relig 23% Self-efficacy (Soc) 34% SocNet: pro-abst. 16% SocNet: pro-drk. 24% Aftercare (PDA) Self-efficacy (NA) 1% Depression 2% Spirit/Relig 6% Self-efficacy (Soc) 27% SocNet: pro-abst. 31% SocNet: pro-drk. 33% Outpatient (PDA) Self-efficacy (NA) 20% Depression 11% Spirit/Relig 21% Self-efficacy (Soc) 21% SocNet: pro-abst. 11% SocNet: pro-drk. 16% Aftercare (DDD) Self-efficacy (NA) 1% Depression 5% Spirit/Relig 9% Self-efficacy (Soc) 39% SocNet: pro-abst. 17% SocNet: pro-drk. 29% Outpatient (DDD) 52

Source: Kelly, JF, Hoeppner, B. Stout, RL, Pagano, M. (2011) Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous,

Addiction

Social recovery

environment particularly high risk for youth; substance use rising and peaking in emerging adulthood; common precursor to relpase

AA ATTENDANCE AND THE % CHANGE IN BOTH PRO-ABSTINENT AND PRO-DRINKING NETWORK TIES FROM TREATMENT INTAKE

TO THE 9-M (OP SAMPLE)

AA ATTENDANCE AND THE % CHANGE IN BOTH PRO-ABSTINENT AND PRO-DRINKING NETWORK TIES FROM TREATMENT INTAKE

TO THE 9-M (AC SAMPLE)

TSF D

ELIVERY

M

ODES

T S F O T H

Component of a treatment package (e.g., an additional group) Stand alone

Independent therapy Integrated into an existing therapy

As Modular appendage linkage component

e.g., Timko et al, (2006; 2007; 2011); Kahler et al, (2005); Sisson and Mallams, (1981)

e.g., Kaskutas et al, (2009)

e.g., Walitzer et al, (2008); Litt et al, (2009) e.g., Project MATCH

Research Group (1997); Litt et al, (2009)

O

VERVIEW



Background and Context



Rationale and Conceptualization: Addiction Recovery

Management



Mutual-help organizations



The role of mutual-help organizations in recovery

W

HAT

ABOUT

Y

OUTH

?

P

OTENTIAL

D

EVELOPMENTAL

B

ARRIERS

:

 Only 2% of AA and NA members are under the age of 21; 13% under

30yrs

 Youth-adult differences:

 Recovery Specific:

- Addiction severity (withdrawal/consequences)

- Problem recognition/motivation for abstinence

 Life-Context Specific:

- Younger age relative to AA/NA members mismatch with life-context factors (e.g., marriage, children, employment problems) /safety issues

- Dependence on parents for transportation/financial support

 12-step Specific:

- Potential discomfort with spiritual/”religious”

 May signify poor fit with 12-step fellowships’ emphases on complete

Y

OUTH

-S

PECIFIC

AA/NA

OUTCOMES

K

NOWLEDGE

:

Authors Year N Follow-up _(Months) % Female M Age _{(No. of sites)}Setting

Alford, Koehler, Leonard 1991 157 6, 12, 24 38% 16 Inpatient (1)

Brown 1993 140 12 42% 16 Inpatient (2)

Kennedy & Minami 1993 91 12 23% 16.5 Inpatient (1)

Hsieh, Hoffman, Hollister 1998 2,317 6, 12 35% 17-19 Inpatient (24)

Kelly, Myers, Brown 2000 99 6 60% 16 Inpatient (2)

Kelly, Myers, Brown 2002 74 6 62% 16 Inpatient (2)

Mason and Luckey 2003 95 3, 12 32% 22 Inpatient (2)

Grella, Joshi, Hser 2004 810 12 30% 16 Residential (8),STI _{(6), Outpatient (9)}

Kelly, Myers, Brown 2005 74 6 62% 16 Inpatient (2)

Kelly, Brown et al 2008 160 6, 12, 24, 48, 72, 96 34% 13-18 Intensive outpatient ₍₄₎ Chi, Kaskutas, Sterling et

al 2009 419 6, 12, 36 34% 13-18 Intensive outpatient (4)

Kelly, Dow, Yeterian 2010 127 3, 6 24% 16.7 Outpatient (1)

Chi, Sterling, Campbell, Weisner

In press 419 12, 36, 60, 72, 84 34% 13-18 Intensive outpatient(4)

Kelly and Urbanoski In press 127 3, 6, 12 24% 16.7 Outpatient (1)

R

ESULTS

: R

ATES

OF

A

TTENDANCE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

0-6m 6m-1yr 1-2yr 2-4yr 4-6yr 6-8yr

Follow-Up % A tt e nd ing A A /N A Any Monthly Weekly

Any, Monthy, and Weekly AA/NA Attendance across 8 Years Following Inpatient Treatment

0 10 20 30 40 50 60 70 80 90 100 6m 12m 24m 48m 72m 96m % A tt end ing A A /N A w ee kly Time

8 Year follow-up across young adulthood : Trajectory Outcome Group attending AA/NA at least Weekly

Abstainers

Infrequent User

worse with time

Frequent User

Kelly JF, Brown SA, Abrantes, A. et al. Social Recovery Model: An 8-Year Investigation of Youth Treatment Outcome in Relation to 12-step Group Involvement. Alcoholism: Clinical and Experimental Research, 2008, 32, 8 1468-1478.

61

L

AGGED

GEE M

ODEL OF

Y

OUTH

T

REATMENT

O

UTCOME IN

RELATION TO

AA/NA

ATTENDANCE OVER

8 Y

EARS

Kelly JF, Brown SA, Abrantes, A. et al. Social Recovery Model: An 8-Year Investigation of Youth Treatment Outcome in Relation to 12-step Group Involvement. Alcoholism: Clinical and Experimental Research, 2008, 32, 8 1468-1478.

Parameter Estimate Standard Error 95% Confidence Limits Z P Intercept 37.3071 6.9601 23.6656 50.9486 5.36 <.0001 Time 1.4424 0.8693 -0.2614 3.1462 1.66 0.0971 Gender -9.3380 2.6605 -14.5526 -4.1234 -3.51 0.0004 Pre-treatment PDA -0.0811 0.0490 -0.1772 0.0150 -1.65 0.0980 Moderate use -1.8816 0.9646 -3.7722 0.0090 -1.95 0.0511 Aftercare1 6m 0.4349 0.5158 -0.5761 1.4460 0.84 0.3991 Formal Treatment2 5.5669 3.2856 -0.8727 12.0065 1.69 0.0902 AA/NA2 1.9517 0.4512 1.0674 2.8360 4.33 <.0001 PDA2 0.5030 0.0371 0.4304 0.5757 13.56 <.0001

1= Sq root transformed; 2= Time varying covariate

On average over the 8 yr follow-up, youth gained an additional 2 days of abstinence for every AA/NA meeting attended over and above all other factors associated with better outcome

E

MERGING

ADULTS

AND

AA:

BENEFITS

IN

THE

YEAR

FOLLOWING

INPATIENT

TREATMENT



303 emerging adults, 18-24yrs; 26% female; 95%

White; 51% had comorbid axis I disorders



Assessed at intake and 1, 3, 6, and 12 months

following residential treatment

AA/NA

ATTENDANCE

ACROSS

TIME

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Pre-tx 1m post-tx 3m post-tx 6m post-tx 12m post-tx Source: Kelly, Stout, Slaymaker

H

AVING

AN

AA/NA

SPONSOR

ACROSS

TIME

0% 10% 20% 30% 40% 50% 60%

Pre-tx 1m post-tx 3m post-tx 6m post-tx 12m post-tx

Source: Kelly, Stout, Slaymaker (2012)

S

UBSTANCE

USE

OUTCOMES

AND

AA/NA



Controlling for substance use at treatment

intake, higher AA/NA attendance associated with

higher PDA across all follow-ups (M d = .55;

sps<.0001)



Having an AA/NA sponsor was related to better

outcomes and partially mediated the effects of

attendance on outcomes (Ps<.001).



Oversight/accountability provided by recovering

peer may enhance recovery outcomes

Source: Kelly, Stout, Slaymaker (2012)

66

67

Incremental benefits of select aspects of

12-step involvement

W

ITHIN

-

PERSON CHANGE IN

PDA

FOR DISCRETE SUB

-

GROUPS OF

AA/NA

ATTENDEES FOLLOWING OUTPATIENT

SUD

TREATMENT

(N=111)

0 10 20 30 40 50 60 70 80 90

Admission 3 months 6 months 12 months

None (n=61)

Inconsistent (n=43) Weekly (n=7)

12-step attendance after admission:

Kelly, JF, Urbanoski, K. (In press) Youth Recovery Contexts: The incremental effects of 12-step attendance and involvement on adolescent outpatient outcomes Alcoholism: Clinical Experimental Research.

All teens Mostly teens Even mix Mostly adults All adults Me an D ay s A bs tin en t 100 95 90 85 80 75 70 65 60 55 50 Days Abstinent (3m) Days Abstinent (6m)

Kelly JF, Myers, MG Brown SA (2005). The effect of age composition of 12-step meetings on adolescent attendance and outcomes Journal of Child and Adolescent Chemical Dependency.

Moderators: Might Age Composition of AA/NA meetings moderate participation and derived benefits?

S

TATE OF THE

S

CIENCE OF

P

EER

-

BASED

M

UTUAL

-H

ELP FOR YOUNG PEOPLE



All studies correlational/observational (self-selection);

varying degrees of scientific rigor to help rule out

self-selection



Of all studies, only 2 samples examined effects among

young adults (18-25)



Small to moderate effect sizes (similar to adult studies)



Higher 12-step participation rates seen among more

severe, 12-step-oriented inpatient samples; lower among

outpatients/CBT oriented programs



No experimental studies of TSF linkage strategies (one

underway)



Outcomes measured mostly restricted to alcohol/drug with

limited focus on other recovery outcomes (e.g., educational

attainment; absenteism; arrests; health)

S

UMMARY

 Recovery support services provide meaningful indigenous help

within the environments in which people live; help build and sustain recovery capital.

 Developmental milestones of education and training may be key

to long term recovery as well as physical and mental health

 Few comparative studies examining the utility and impact of

recovery support services (exception: recovery homes).

 Peer-based mutual-help has increasing evidence for benefit of a

similar magnitude to adults

 TSF is an empirically supported treatment for adults, but

experimental studies of MHG facilitation needed to evaluate among young people

 College recovery initiatives which often incorporate 12-step

philosophy, show great promise with high retention, low relapse rates, and higher than average GPA, but await more rigorous comparative evaluation

A

CKNOWLEDGEMENTS



Special thanks to Veselina Hristova, BA, for her

help in preparing this presentation.