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Treating Addiction as a chronic disease John F. Kelly, Ph.D. Elizabeth R. Spallin Associate Professor of Psychiatry in Addiction Medicine Harvard Medical.

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Presentation on theme: "Treating Addiction as a chronic disease John F. Kelly, Ph.D. Elizabeth R. Spallin Associate Professor of Psychiatry in Addiction Medicine Harvard Medical."— Presentation transcript:

1 Treating Addiction as a chronic disease John F. Kelly, Ph.D. Elizabeth R. Spallin Associate Professor of Psychiatry in Addiction Medicine Harvard Medical School Director Recovery Research Institute MGH Center for Addiction Medicine Faxton St. Lukes, October 17 th 2014

2 Disclosure of Relevant Financial Relationships Content of Activity: Faxton St. Lukes Talk Date of Activity: Octobr 17th 2014 NameCommercial Interests Relevant Financial Relationships: What Was Received Relevant Financial Relationships: For What Role No Relevant Financial Relationships with Any Commercial Interests x

3 R ECOVERY R ESEARCH I NSTITUTE L AUNCH O CTOBER 30, 2013 WWW. RECOVERYANSWERS. ORG

4 M ONTHLY N EWSLETTER

5 Sign up for Newsletter at:

6 OUTLINE Definitions, terminology, and stigma Acute vs chronic care model Conceptualizations of addiction and recovery Addiction recovery management models

7 OUTLINE Definitions, terminology, stigma, and discrimination

8 H EALTH CARE IS CHANGING AND SUD IS (F INALLY ) BECOMING AN IMPORTANT FOCUS IN THAT CHANGE

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10 D EFINITIONS, TERMINOLOGY, STIGMA AND DISCRIMINATION Should we use the term “Chronic disease”? Or, “alcohol/drug problem? Or call it “substance abuse/abuser”? Does it really matter what we call it or them? Is it chronic? Is it a “disease”?

11 W HAT IS A “ DISEASE ”? “a disordered or incorrectly functioning organ, part, structure, or system of the body resulting from the effect of genetic or developmental errors, infection, poisons, nutritional deficiency or imbalance, toxicity, or unfavorable environmental factors.” – Dictionary.com “ a condition of the living animal or plant body or of one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms” - Miriam Webster It matters, because the words we use influence our conceptualizations and approaches to it (e.g., “War on drugs” “You use you lose” vs addiction as a public health problem)

12 “C HRONIC ”? W HO (2014) “Noncommunicable diseases (NCDs), also known as chronic diseases, are not passed from person to person. They are of long duration and generally slow progression. The four main types of noncommunicable diseases are cardiovascular diseases (like heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructed pulmonary disease and asthma) and diabetes.”

13 N OT ALL THOSE WHO MEET CRITERIA FOR SUD HAVE CHRONIC TRAJECTORIES … E PIDEMIOLOGIST ’ S ILLUSION VS. CLINICIAN ' S ILLUSION NSDUH and Dennis & Scott No Alcohol or Drug Use Light Alcohol Use Only Any Infrequent Drug Use Regular AOD Use Abuse Dependence Age Groups Severity Category

14 14 R EMISSION OF D EPENDENCE I S C OMMON, BUT FOR S OME I NDIVIDUALS ’ D EPENDENCE C AN S PAN D ECADES Source: NIAAA NESARC data ( years of age) and SAMHSA 2003 NSDUH (12-17 years of age). High remission rates But for some, chronic, harmful course…

15 S UBTYPES – BUT IDENTIFICATION OF CLINICALLY MEANINGFUL SUBTYPES CHALLENGING … T YPOLOGY I NVESTIGATIONS Silkworth (1939) Jellinek (1960) Cloninger (1981) Babor (1992) Del Boca (1994) Del Boca (1996) Hesselbrock (2006) Moss (2007) Anton (2008)

16 Addiction Onset Help Seeking Full Sustained Remission (1 year abstinent) Relapse Risk drops below 15% 4-5 years 8 years 5 years Self- initiated cessation attempts 4-5 Treatment episodes/ mutual- help Continuing care/ mutual- help For more severely dependent individuals … course is chronic but remission most likely outcome 60% of individuals with addiction will achieve full sustained remission (White, 2013) Opportunity for earlier detection through screening in non-specialty settings like primary care/ED

17 A DDICTION IS HEAVILY STIGMATIZED AND THE LANGUAGE WE USE MAY AFFECT STIGMA / DISCRIMINATION SUDs most stigmatized of all social/health problems Most Stigmatized National surveys show stigma one of main reasons people with SUD do not seek specialty care (SAMHSA, 2009) Nationally WHO examined 18 most stigmatized conditions (eg. criminal, HIV, homeless) across 14 different countries (Room et al 2001) Drug addiction- #1 - most stigmatized Alcohol addiction- 4 th most stigmatized Internationally Ambivalence influenced by stigma and contributes to few accessing care (only 10% seek specialty care/yr) Poor access

18 L ANGUAGE SURROUNDING CLINICAL CARE IN ADDICTION IS UNLIKE ANY OTHER AREA OF MEDICINE - MAY AFFECT QUALITY AND EFFECTIVENESS OF CARE A patient suffering from diabetes has “an elevated glucose”. A patient with cardiovascular disease has “a positive exercise tolerance test” Someone inside the healthcare system addresses the results. An “addict” isn’t “clean”—he has been “abusing” drugs and has a “dirty ” urine. Someone outside the system that cares for all other health conditions addresses the results. In the worst case, the drug use is addressed by incarceration.

19 SUD S TIGMA /D ISCRIMINATION MODERATED BY TWO FACTORS … CAUSE Did they cause it ? “It’s not their fault” (decreases stigma; increase compassion) CONTROLLABILITY Can they help it ? “They can’t help it” (decreases stigma; increases compassion)

20 T WO COMMONLY USED TERMS … Referring to someone as… “a substance abuser” – implies perpetration/willful misconduct (they CAN help it) “having a substance use disorder” – implies victim/medical malfunction (they CAN’T help it)

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22 22 How we talk and write about these conditions and individuals suffering them does matter

23 Mr. Williams is a substance abuser and is attending a treatment program through the court. As part of the program Mr. Williams is required to remain abstinent from alcohol and other drugs. He has been doing extremely well, until one month ago, when he was found to have two positive urine toxicology screens which revealed drug use and a breathalyzer reading which revealed alcohol consumption. Within the past month there was a further urine toxicology screen revealing drug use. Mr. Williams has been a substance abuser for the past six years. He now awaits his appointment with the judge to determine his status. Mr. Williams has a substance use disorder and is attending a treatment program through the court. As part of the program Mr. Williams is required to remain abstinent from alcohol and other drugs. He has been doing extremely well, until one month ago, when he was found to have two positive urine toxicology screens which revealed drug use and a breathalyzer reading which revealed alcohol consumption. Within the past month there was a further urine toxicology screen revealing drug use. Mr. Williams has had a substance use disorder for the past six years. He now awaits his appointment with the judge to determine his status. Doctoral-level clinicians (n=561) randomized to receive one of two terms….

24 24 Figure 1. Subscales comparing the “substance abuser” and “substance use disorder” descriptive labels Kelly, JF, Dow, SJ, Westerhoff, C. Does our choice of substance-related terms influence perceptions of treatment need? An empirical investigation with two commonly used terms (2010) Journal of Drug Issues

25 I MPLICATIONS Exposure to the “abuser” term may activate an implicit more punitive cognitive bias Learn from our friends in other fields : Individuals with “eating related problems” are uniformly described as “having an eating disorder” NEVER as “food abusers”

26 S TOP TALKING “ DIRTY ”: CLINICIANS, LANGUAGE, AND QUALITY OF CARE FOR THE LEADING CAUSE OF PREVENTABLE DEATH IN THE U NITED S TATES K ELLY, JF, W AKEMAN, SE, S AITZ, R. A MERICAN JOURNAL OF MEDICINE ( IN PRESS ) Avoid stigmatizing terminology such as “dirty” vs “clean” utox screens, instead of “negative/positive”. Recommendations: Use “person first” language - refer to individuals with addiction as people with a “substance use disorder” not as substance “abusers” or “addicts.” For those with consequences or risk, but not a disorder (often referred to inaccurately as “abuse”), use “hazardous”, “risky”, or “harmful” use, or for the full spectrum that includes risk to a disorder, “unhealthy” use. …commit to a medically appropriate lexicon which conveys the same dignity and respect we offer to other individuals suffering from an array of medical problems.

27 OUTLINE Acute vs chronic care model

28 Addiction Onset Help Seeking Full Sustained Remission (1 year abstinent) Relapse Risk drops below 15% 4-5 years 8 years 5 years Self- initiated cessation attempts 4-5 Treatment episodes/ mutual- help Continuing care/ mutual- help For more severely dependent individuals course of addiction is chronic … 60% of individuals with addiction will achieve full sustained remission (White, 2013) Opportunity for earlier detection through screening in non-specialty settings like primary care/ED

29 If really believed addiction is chronic we would not: View prior tx failure as a poor prognostic indicator Convey the expectation that all clients should achieve complete, enduring sobriety following single, brief treatment episode Punitively d/c clients for becoming symptomatic/confirming their diagnosis Relegate continuing care to an afterthought Terminate the service relationship following acute care Treat serious and persistent SUD in serial episodes of self- contained and unlinked interventions B UT, W HAT IF REALLY B ELIEVED A DDICTION WAS A C HRONIC D ISORDER ? White and Kelly (2011)

30 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: Recovery management is a philosophy of organizing addiction treatment and recovery support services to enhance early pre-recovery engagement, recovery initiation, long-term recovery maintenance…( White & Kelly, 2011).

31 OUTLINE Conceptualizations of addiction and recovery

32 A DDICTION IS A … A disease of the brain that affects the neuro-circuitry of reward, memory, motivation, impulse control, and judgment For recovery to occur, accurate risk appraisals must be conducted and frequent adaptive decisions made and actions taken (prefrontal cortex) to inhibit impulses and gradually correct dysregulated reward system (limbic system) Rewards of use are immediate, concentrated, predictable; rewards of recovery are delayed, diffuse, and variable Recovery is a demanding, effortful, process requiring constant vigilance to protect against the risk of relapse and can lead to frustration and exhaustion… W HY DO PEOPLE HAVE A HARD TIME STAYING SOBER AND IN REMISSION ?

33 General Adaptation Syndrome (Selye, 1956) Alarm – Resistance – Exhaustion “… after self-control efforts, subsequent attempts at self-control are more likely to fail. Continuous self- control efforts, such as vigilance, also degrade over time…These decrements appear to be specific to behaviors that involve self-control (Muraven & Baumeister, 2000). Post-acute withdrawal and need to learn complex recovery coping skills – stressful; taxes available coping resources - affects relapse risk Need to find ways to replenish cognitive resources to inhibit thoughts and impulses to use substances over time… W HY DO PEOPLE HAVE A HARD TIME STAYING SOBER AND IN REMISSION ?

34 In fact, the recovery construct, like the addiction construct, is made up of two reciprocal factors: “remission” and the consequences of that remission, “recovery capital”; as longer remission is achieved, more capital accrues, BUT also, remission can be influenced the other way - as more recovery capital accrues so the chances of continued remission increase. Kelly and Hoeppner (2014) A biaxial formulation of the recovery construct, Addiction Research and Theory

35 35 D ECREASE STRESS AND REPLENISH COPING RESOURCES BY PROVIDING RM AND R ECOVERY S UPPORT S ERVICES Recovery Management and MonitoringRecovery Mutual-help organizationsRecovery High schoolsCollegiate Recovery Support programsRecovery Community CentersRecovery Community Organizations

36 OUTLINE Addiction recovery management models

37 Clinically, we’ve learned that prized- based CM approaches can produce large effects while contingencies in place …. But advantage disappears by 6m once removed

38 Examples of Long-term recovery management programs Physicians Health Programs Hawaii Opportunity Probation with Enforcement (HOPE) South Dakota “24/7” Clinical Recovery Management Check-ups Mutual-help organizations

39 P HYSICIANS H EALTH P ROGRAMS Emerged in 1970s, through the American Medical Association to help alcohol/drug impaired physicians Services provided include: - professional intervention services - referral to formal evaluation - referral to formal treatment - long-term monitoring Source: White, W.L., DuPont, R.L. & Skipper, G.E. (2007)

40 K EY INGREDIENTS OF PHP S motivational fulcrum : link recovery to positive rewards and relapse to negative consequences (e.g., loss of license) comprehensive assessment and treatment : patient-oriented treatment rather than a fixed model care management oversight role : PHPs directs care for physicians so they can select appropriate resources high expectation for abstinence-based recovery : relapses are seen as temporary setbacks/learning experiences assertive linkage to recovery support groups : active referrals to 12- step and other recovery-focused mutual aid groups sustained monitoring support reintervention : periodic interviews/random urine testing over 5 years reintervention at higher level of intensity : relapse and reintervention are followed by reevaluation and more intensive/prolonged treatment integrated comprehensive program : PHPs include these items in an integrated and long-sustained program Source: Skipper, G.E. and DuPont, R.L. (2011)

41 PHP S 5-7 YR STUDY OUTCOMES (N=904) 72% completed the contract; a further 22% signed a new one (78% of these voluntarily) 79% licensed and working at 5-year follow-up 92% participated in AA or NA; 61% participated in continuing groups 78% had zero positive tests across 5-7 yrs; 22% had at least one positive test at some point, however, only 1 in 200 drug screens were positive over the 5-7yr monitoring period Source: Du Pont, R.L. et al. (2011)

42 H AWAII O PPORTUNITY P ROBATION WITH E NFORCEMENT (HOPE) PROGRAM Goal - to reduce drug use, new crimes, and incarceration Drug-testing-and-sanctions approach Does not mandate treatment; 12-step participation encouraged Started as pilot program 2004 with 36 offenders now expanded to over 1500 participants 2009

43 P ILOT STUDY BY THE I NTEGRATED C OMMUNITY S ANCTIONS UNIT IN H ONOLULU Offenders in HOPE vs. comparison offenders HOPE procedure: - initiation/overview conducted by judge - call HOPE hotline every morning - if selected for testing, must appear by 2pm - if fail to appear or test positive, “Motion to Modify Probation” issued - after immediate hearing, if offender has violated probation, sentenced to short jail stay (several days) - HOPE participation resumes upon release Probation as usual: - no random drug testing - scheduled appointments with a probation officer once a month

44 A VERAGE NUMBER OF POSITIVE UA S, BY PERIOD. (H AWKEN ET AL., 2009) In a 12-month period 61% of HOPE participants had zero positive UAs Note: Data are from PROBER. For comparison probationers, data reflect urinalysis results for regularly scheduled UAs. For HOPE probationers UAs include regularly scheduled tests, and random testing. Pre (3m) refers to the average number of missed appointments in the three months before the study start date (baseline). Follow-up (3m) refers to the average number of missed appointments in the three-month period following baseline and Follow-up (6m) refers to the average number of missed appointments in the six-month period following baseline.

45 R ANDOMIZED CONTROLLED TRIAL OF HOPE (N=493) (H AWKEN ET AL., 2009) HOPE vs. probation-as-usual One year follow up Results HOPE in comparison with probation-as-usual: - 60% fewer no-shows - 70% fewer positive urine tests - 55% fewer new arrest rates - 53% lower revocation rate - 48% lower incarceration

46 S OUTH D AKOTA ’ S “24/7 S OBRIETY ” PROJECT (L ARRY L ONG ) For repeat DUI offenders Started 1980s in 1 county; 2007 implemented state-wide -replicated in North Dakota Objective verification of abstinence (twice a day breath, blood or other bodily substance testing Positive/missed tests results in immediate 24- hour incarceration No treatment referral or requirement; 12-step attendance encouraged

47 24/7 S OBRIETY O UTCOMES Urinalyses (July 1, 2007-July 20, 2011): N= 1,990 46,648 tests administered Pass Rate 96.9% SCRAM bracelets (Nov. 6, 2006-July 20, 2011): N=3, % had no violations 22.1% participants had some type of violation Drug patches (July 1, 2007-July 20, 2011): N=94 Pass Rate 80% Source:

48 A Example of the benefit of treating addiction like a chronic condition: 4-year outcomes from the Early Re-Intervention experiment using Recovery Management Checkups N=446 adults with SUD, mean age = 38, 54% male, 85% African-American randomly assigned to quarterly assessment only quarterly assessment plus RMC Recovery Management Checkups Linkage manager who used motivational interviewing to review the participant’s substance use, discuss treatment barrier/solutions, schedule an appointment for treatment re-entry, and accompany participant through the intake If participants reported no substance use in the previous quarter, the linkage manager reviewed how abstinence has changed their lives and what methods have worked to maintain abstinence Source: Dennis & Scott (2012). Drug and Alcohol Dependence, 121, 10-17

49 R ESULTS 1 R ETURN TO TREATMENT Participants in RMC condition sig. more likely to return to treatment sooner Source: Dennis & Scott (2012). Drug and Alcohol Dependence, 121, 10-17

50 R ESULTS 4 D AYS ABSTINENT (0-1350) *p<.01 Of 18 vars tested, the only variables that predicted return to treatment was the intervention

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52 W HAT ABOUT MHO S ’ ROLE IN CHRONIC RECOVERY MANAGEMENT ?

53 S OCIETAL R ESPONSE TO SUD AND RELATED PROBLEMS. W HY HAVE MHO’ S GROWN DESPITE BETTER MORE EFFECTIVE PROFESSIONAL TREATMENTS While increases in quality and quantity of SUD treatment over past 40yrs…. …professional resources alone cannot cope; stigma and cost present further barriers to formal tx access Addiction often has chronic course (8 yrs from 1 st tx to achieve FSR; Dennis et al, 2005); 4-5 yrs before risk of relapse <15% In tacit recognition, most societies seen increases in MHOs during past 75 yrs (Kelly & Yeterian, 2008) “The burden of alcohol problems is a heavy one; the specialized treatment sector is necessarily limited in size and quite costly. The committee believes that only a shared effort can succeed in lifting this burden to any significant degree” (IOM, 1990)

54 P OTENTIAL A DVANTAGES OF C OMMUNITY M UTUAL - HELP IN RECOVERY MANAGEMENT Cost-effective -free; attend as intensively, as long as desired Focused on addiction recovery management over long term Widely available, easily accessible/flexible Provide access at high risk times when professional services not available (e.g., nights/ weekends/holidays) Entry threshold (no paperwork, insurance); anonymous (stigma) Adaptive community based system that is responsive to undulating relapse risk

55 Name Year of Origin Number of groups in U.S. Location of groups in U.S. Alcoholics Anonymous (AA) ,000 all 50 States Narcotics Anonymous (NA) 1940s Approx. 20,000 all 50 States Cocaine Anonymous (CA) 1982 Approx groups most States; 6 online meetings at Methadone Anonymous (MA) 1990s Approx. 200 groups 25 States; online meetings at Marijuana Anonymous (MA) 1989 Approx. 500 groups 24 States; online meetings at Rational Recovery (RR) 1988 No group meetings or mutual helping; emphasis is on individual control and responsibility Self-Management and Recovery Training (S.M.A.R.T. Recovery) 1994 Approx. 500 groups 40 States; 19 online meetings at Secular Organization for Sobriety, a.k.a. Save Ourselves (SOS) 1986 Approx. 500 groups all 50 States; Online chat at Women for Sobriety (WFS) groups Online meetings at WomenforSobriety Moderation Management (MM) 1994 Approx.18 face-to-face meetings 12 States; Most meetings are online at MHOs are prolific resources well-suited to RM approaches to SUD Source: Kelly & Yeterian, 2008

56 Table 2. Dual-Diagnosis Focused Mutual-help Groups NameYear of Origin Number of groups in U.S. Location of groups in U.S. Double Trouble in Recovery (DTR) Highest number of groups in NY, GA, CA, CO, NM, FL Dual Recovery Anonymous (DRA) Highest number of groups in CA, OH, PA, MA Dual Disorders Anonymous in IL Dual Diagnosis Anonymous (DDA)7638 in CA Source: Kelly & Yeterian, 2008)

57 Table 3. Non-Substance Focused Addictive Behavior Mutual-help Groups Name Year of Origin Number of groups in U.S.Location of groups in U.S. Gamblers Anonymous (GA) 1957Approx chaptersall 50 States Sex Addicts Anonymous (SAA) 1977Approx. 700 meetings most States; Online meetings at Telephone meetings Sex and Love Addicts Anonymous (SLAA) 1976 Approx groups worldwide (including in all 50 States), Online meetings at ml; Regional teleconference calls ml Overeaters Anonymous (OA) 1960 Approx. thousands of meetings all 50 States; Numerous online (www.oa.org/pdf/OnlineMeetingsList.p df) and telephone meetings (www.oa.org/pdf/phone_mtgs.pdf)www.oa.org/pdf/OnlineMeetingsList.p dfwww.oa.org/pdf/phone_mtgs.pdf Source: Kelly & Yeterian, 2008)

58  Effectiveness: Do they help?  Millions attend 12-step MHOs and many continue long-term  Rigorous experimental, quasi- experimental, correlational, and observational studies support MHOs as stand alone or adjunct to treatment  Potentiate and extend treatment outcomes and reduce health care costs  Work through mechanisms similar to those operating in formal tx  Clinical (12-step facilitation) strategies can enhance participation and outcomes

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60 E VIDENCE OF B ENEFIT - M ETA A NALYSES OF AA  4 meta-analytic reviews  Emrick et al  Tonigan et al, 1996  Kownacki et al  Ferri, Amato, & Davoli, 2006

61 R ESULTS AND L IMITATIONS Results from hundreds of studies reveal AA confers a consistent moderate beneficial effect in par with professional treatment Results from RCTs of AA itself, reveal mixed findings depending on whether individuals were coerced/mandated to attend AA meetings or not Most attended following treatment –difficult to discern unique effects of AA…

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66 Odds of Abstinence 4 Months -Completed treatment -Attended 12-step meetings on a weekly or more basis -Completed treatment -Did not attend 12- step meetings -Remained in treatment -Did not complete treatment -Did not attend 12- step meetings 2 Months -Did not complete treatment -Did not attend 12- step meetings Fiorentine and Hillhouse (2000)

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68 H EALTH C ARE COST OFFSET CBT VS 12-STEP RESIDENTIAL TREATMENT 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 ($15M total savings) Also, higher remission rates, means decreased disease and deaths, increased quality of life for sufferers and their families

69 A DOLESCENT H EALTH C ARE C OST O FFSET 7- YEAR S TUDY N = 403 adolescents, age Follow-up: 6 months, 1, 3, 5, and 7 years 12-step attendance associated with better outcomes over the 7 yr period Avg annual medical costs for all participants over 7 years: $3085 per person per year 4.7% decrease in medical costs with each additional 12-step meeting attended = $145 annual savings per 12-step meetings attended Source: Mundt, Parthasarathy, Chi, Sterling, Campbell (2012) Mundt et all,, 2012, Drug and Alcohol Dependence

70 T OWARD T WELVE - STEP FACILITATION Evidence: Millions have attended; half of AA members of 5 yrs or more of sobriety; attendees report benefitting Positive results from more than a hundred correlational/ quasi-experimental and experimental studies Facilitating linkage enhances abstinence/remission and reduces health care costs If we really believed addiction was a chronic disease and MHOs were shown to increase remission rates shouldn’t we try to link patients with them?

71 Can what we do in treatment increase long-term engagement with MHOs and thereby enhance recovery outcomes?

72 D OES F ACILITATION D URING T X A FFECT R ISK FOR D ROPOUT ? Dropout rate = 40% AA dropouts had 3x higher odds of relapse to alcohol/drug use

73 F ACILITATION BY D ROPOUT -R ISK I NTERACTION Source: Kelly & Moos (2003) Dropout from 12-Step Groups: Prevalence, Predictors and Counteracting Treatment Influences, Journal of Substance Abuse Treatment,24,

74 P RECURSOR TO C URRENT TSF R ESEARCH (S ISSON AND M ALAMS, 1981) 20 patients randomly selected from outpatient tx program for alcohol use disorder Randomly assigned to: 1: Standard referral given information about AA including time, date, location of meetings, encouraged to attend meetings 2: Systematic encouragement and community access In addition to standard procedure, clients had phone conversation with AA member during a session - client and AA member met before first meeting, member provided client with ride; client also received a reminder phone call from the member

75 P RECURSOR TO C URRENT 12-S TEP F ACILITATION R ESEARCH Results: 0% clients in standard referral attended a meeting during the target week 100% clients in systematic encouragement and community access group attended meeting during target week Mean AA meeting attendance rate for 4 week period: 0 for standard referral group vs 2.3 for systematic encouragement group

76 TSF D ELIVERY M ODES Stand alone Independent therapy Integrated into an existing therapy Component of a treatment package (e.g., an additional group) As Modular appendage linkage component TSFTSF OTHOTH

77 TSF D ELIVERY M ODES Stand alone Independent therapy Integrated into an existing therapy Component of a treatment package (e.g., an additional group) As Modular add-on linkage component TSFTSF OTHOTH

78 I. P ROJECT MATCH- R ESULTS Similar on continuous outcomes (PDA/DDD)  Across txs, AA attendees had better outcomes (Tonigan et al, 2002)  AA valuable adjunct to treatment - even when not formally emphasized  Individuals assigned to TSF attended AA more frequently and had substantially higher rates of continuous abstinence at 1yr and 3yrs

79 C HANGING N ETWORK S UPPORT FOR D RINKING (L ITT ET AL., 2009) Network Support Project -to determine if tx can change social networks to ones supportive of sobriety Alcohol dependent individuals (N=210) randomly assigned to 1 of 3 txs: Network Support (NS) Meant to help patients change social network to include people in support of abstinence; based on TSF treatment created for Project MATCH; 6 core sessions+ 6 elective sessions Network Support +Contingency Management (NS+CM) Same network support as described above, plus drawings from a “fishbowl” if soc. network enhancing tasks completed (eg. AA meeting, having coffee with a sober friend) Case Management (CaseM, control condition) Based on intervention used in Marijuana Treatment Project; therapist and participant worked together to indentify barriers to abstinence and develop goals and identify resources to be used to aid in achieving abstinence

80 C HANGING N ETWORK S UPPORT FOR D RINKING - F INDINGS Network Support: Higher PDA More total abstinent Lower consequences Lower DDD

81 TSF D ELIVERY M ODES Stand alone Independent therapy Integrated into an existing therapy Component of a treatment package (e.g., an additional group) As Modular add-on linkage component TSFTSF OTHOTH

82 S TRATEGIES FOR F ACILITATING O UTPATIENT A TTENDANCE OF AA (W ALLITZER ET AL, 2008) Approaches to assist in involvement in AA 169 adult alcoholic outpatients randomly assigned to one of three treatment conditions All clients received treatment that included: 12 sessions Focus on problem-solving, drink refusal, relaxation Recommendation to attend AA meetings

83 S TRATEGIES FOR F ACILITATING O UTPATIENT A TTENDANCE OF AA Treatment varied between 3 conditions in terms of how the therapist discussed AA and how much information about AA was shared Condition 1: Directive approach Therapist directed Client signed contract describing goals to attend AA meetings Therapist encouraged client to keep a journal about meetings Reading material about AA provided to client Therapist informs client about skills to use during meetings and about using a sponsor 38% total material covered in sessions was about AA Condition 2: motivational enhancement approach (more client centered) Therapist obtains clients feelings and attitudes about AA Therapist describes positive aspects of AA, but states that it is up to the client how much they will be involved Therapist intends to assist the client in making a decision in favor of AA 20% total material covered in sessions about AA Condition 3: CBT treatment as usual, no special emphasis on AA Throughout treatment, therapist briefly inquires about AA and encourages client to attend AA 8% total material covered in sessions about AA Walitzer, Dermen & Barrick, 2009

84 S TRATEGIES FOR F ACILITATING AA A TTENDANCE DURING O UTPATIENT T REATMENT

85 Strategies for Facilitating AA Attendance during Outpatient Treatment

86 TSF D ELIVERY M ODES Stand alone Independent therapy Integrated into an existing therapy Component of a treatment package (e.g., an additional group) As Modular add-on linkage component TSFTSF OTHOTH

87 MAAEZ I NTERVENTION (K ASKUTAS ET AL, 2009) Making AA Easier- manual guided - designed to help clients prepare for AA Goal: to prepare for AA (encourage participation in AA, minimize resistance to AA, and educate about AA) MAAEZ intervention is conducted in a group format to help prepare for group dynamic of AA Facilitator goal: to inform clients about AA and facilitate group interaction Facilitator recommended to be an active member of AA, NA, or CA Discussion format: MAAEZ allows and encourages feedback (referred to as “cross-talk” in MAAEZ), unlike AA which does not allow feedback

88 MAAEZ I NTERVENTION - F INDINGS

89 TSF D ELIVERY M ODES Stand alone Independent therapy Integrated into an existing therapy Component of a treatment package (e.g., an additional group) As Modular add-on linkage component TSFTSF OTHOTH

90 E FFECTIVENESS OF C LINICIAN R EFERRALS TO AA (T IMKO ET AL 2006; 2007) Evaluation of procedures to effectively refer patients to 12-step meetings Individuals with SUDs entering a new outpatient treatment program randomly assigned to a treatment condition and provided self reports on meeting attendance and substance use Condition 1: standard referral Patients given locations and schedules of meetings and encouraged to attend Condition 2: intensive referral Patients give locations and schedules of meetings, with the meetings preferred by previous clients indicated Therapist reviews a handout about program including introduction to 12-step philosophy and common concerns Therapist arranged a meeting with a current member and client had a phone conversation with this member during a session Therapist and client agreed on which meetings client will attend and client kept a journal of meetings attended and experiences

91 E FFECTIVENESS OF C LINICIAN R EFERRALS TO AA- AA P ARTICIPATION F INDINGS Timko 2007

92 E FFECTIVENESS OF C LINICIAN R EFERRALS TO AA- A BSTINENCE O UTCOME F INDINGS

93 RELAPSE Cue Induced Stress Induced Drug Induced How might informal RM resources like MHOs 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 MHO Kelly JF, Yeterian, JD, (2013). Mutual help groups. In McCrady and Epstein. Comprehensive Textbook on Substance Abuse.

94 MHO S R EMOTIVATE PEOPLE OVER TIME MHOs help maintain the salience of the negative consequences of use by facilitating continuous re- exposure (personal stories) and reactivation of painful memories that stimulated the initial recovery attempt (“keep it green”) MHOs provide exposure to recovering role models and observable evidence that recovery and happiness are attainable MHOs impart knowledge/skills, realistic expectations of change MHOs provide encouragement, cheerleading, applause to encourage people to continue; supervision/monitoring MHOs provide access to new social network that can facilitate alternative sober rewarding activities

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96 Source: Kelly, Hoeppner, Stout, Pagano (2012), Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous: A multiple mediator analysis. Addiction 107(2):289-99

97 97 D O MORE AND LESS SEVERELY ALCOHOL DEPENDENT INDIVIDUALS BENEFIT FROM AA IN THE SAME OR DIFFERENT WAYS ? effect of AA on alcohol use for AC was explained by social factors but also by S/R and through negative affect (DDD only) Majority of effect of AA on alcohol use for OP was explained by social factors Source: Kelly, Hoeppner, Stout, Pagano (2012), Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous: A multiple mediator analysis. Addiction 107(2):289-99

98 D O MEN AND WOMEN BENEFIT FROM AA IN THE SAME WAYS ? 98

99 D O YOUNG A DULTS BENEFIT AS MUCH AND IN THE SAME WAYS AS OLDER ADULTS

100 M ODERATED MEDIATION F INDINGS SUGGEST AA-derived recovery benefits differ in nature and magnitude between more severely alcohol involved/impaired and less severely alcohol involved/impaired; men and women; and, young adults and adults 30+ Differences reflect differing needs based on recovery challenges related to differing symptom profiles, degree of subjective suffering and perceived severity/threat, life-stage based recovery contexts, and gender-based social roles & drinking contexts Similar to psychotherapy literature (Bohart & Tollman, 1999) rather than thinking about how AA or similar organizations work, better to think how individuals use or make these organizations work for them – to meet most salient needs at any given phase of recovery

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102 M ODERATED -M ECHANISMS : AA EFFECTS M ODERATED BY S EVERITY, G ENDER, A GE … CONCLUSIONS “Similar to the common finding that theoretically-distinct professional interventions do not result in differential patient outcomes, AA’s effectiveness may not be due to its specific content or process. Rather, its chief strength may lie in its ability to provide free, long-term, easy access and exposure to recovery-related common therapeutic elements, the dose of which, can be adaptively self-regulated according to perceived need. “ Kelly, Magill, Stout (2009)

103 IF WE REALLY BELIEVED ADDICTION WAS A CHRONIC DISEASE WE WOULD … Stop talking dirty: adopt medical lexicon that is consistent with how we describe other conditions Formulate, implement, and evaluate various sequences of services to determine the best practices in RM Support development and testing of long-term cost- effective RM approaches that enhance patients’ self-care and provision of long-term professional monitoring akin to other CDM (e.g., linkage to MHOs and other self-care programs)


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