1. Kathleen Grant MD & L. Brendan Young PhD 39 th Annual National Conference Association for Medical Education & Research in Substance Abuse November 5, 2015 2/17/2016

2. Objectives Participants will be able to Explain to patients the importance of social support in sustaining the gains made during SUD treatment Address patients’ concerns & anxieties regarding self-help group participation Follow up with patients & their family/friends in order to reinforce the importance of a social network supportive of sobriety 2/17/2016

3. Conflicts of Interest Dr. Grant and Dr. Young have no commercial conflicts of interest to report Research support: Veterans Health Administration Office of Rural Health (RH-RHRC) & Quality Enhancement Research Initiative (SUD QUERI) 2/17/2016

4. Background for Intervention 2/17/2016

5. Substance Use Disorders Neuroreceptor-based disorders Neuroreceptor alternations may ‘heal’ w/ abstinence Chronic disorders 2/17/2016

6. Brain images of a person who has never used methamphetamine (left) and of a methamphetamine user after 1 month of abstinence (center). Lighter colors show distribution of dopamine transporters (DAT) in the striatum. DAT distribution is reduced in striatum of methamphetamine user. Brain image of a methamphetamine user after 14 months' abstinence (right) shows substantial recovery of DAT in striatum..

7. SUD Treatment Approach Intensive SUD treatment gives patient tools to deal with factors that increase risk for relapse: Stress Triggers Exposure to substances Continuing Care: Application of tools 2/17/2016

8. Role of Social Support in SUD Treatment 12-Step Self-Help/Mutual-Help Groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Crystal Meth Anonymous Dual Recovery Anonymous Women for Recovery SMART Recovery Overcomers in Christ 2/17/2016

9. 12-Step Support Groups and SUD Treatment Outcomes Self-help group attendance (veterans) Reduce relapse rates & greater abstinence @ 2 years 1 Reduce subsequent SUD treatment utilization 1 Lower health costs 1

10. 12-Step Support Groups and SUD Treatment Outcomes Attendance at NA/AA associated with increased rates of opiate and alcohol abstinence @ 1-, 2-, & 5-years. Stimulants year 1 only 2. (non-veterans)

11. 12-Step Support Groups and SUD Treatment Outcomes Frequency of NA/AA attendance was a better predictor of abstinence than attendance alone 2 Weekly or greater attendance associated with improved outcome 2 Less than weekly or non-attendance equally ineffective 2

12. Why Consider an Intensive Referral Intervention to Support Groups ? Current Practice: Give patient Support Group meeting list & encourage attendance 2/17/2016

13. Study of Intensive Referral in Veterans 3 3-session intensive referral to 12-step support groups Assessed @ 6 & 12 months improve SUD outcomes Yes increase 12-step meeting attendance & involvement Yes 12-step attendance & involvement related to improved SUD outcomes Yes 12-step support group attendance & involvement mediated SUD outcomes Yes

14. AA Involvement 10 ingredients scored 0-10 Read literature Service Had sponsor Been sponsor Had spiritual awakening/conversion Considered self a member 90 meetings/90 days Birthday Called member for help Had sponsor now

15. Results No involvement: 26% abstinent @ 6- & 12- months > 9 ingredients: 83% abstinent @ 6- & 12- months 12-step involvement mediated the association of referral condition with improved SUD outcomes Attendance findings consistent with previous 6 month (alcohol) and 2 year studies (SUD)

16. Intensive Referral Intervention Session 1 Given a schedule of local & preferred NA and AA meetings Reviewed a handout on 12-step meetings Counselor called 12-step volunteer during session and volunteer arranged to meet the patient before AA/NA meeting and attend together Agreed upon meetings to be attended before next session - written into journal given to patient

17. Intensive Referral Intervention Session 2 If no meeting repeated AA/NA volunteer contact Agreed on meetings to attend following week and added to journal Discussed sponsorship

18. Intensive Referral Intervention Session 3 If no meeting repeated volunteer contact Wrote agreement for next week’s meeting attendance Reviewed journal

19. Three Key Elements Linked to 12-step meeting volunteer 12-step journal completed Asked about 12-step attendance

20. Intensive Referral in Dual Disordered Patients 4 IRI compared to Standard Referral Outcomes measured at 6 months Greater attendance and involvement in mutual-help groups Less drug use Better psychiatric outcomes 2/17/2016

21. Intensive Referral Interevention Strengths No additional cost Few exclusions Brief, feasible intervention Multiple settings: Group, Individual, Phone Sessions Residential or Outpatient SUD tx settings Could be done by Addiction Therapists, Peer Support Specialists, primary care, EAP, clergy settings

22. Intensive Referral Modified Urban Rural OPT: Home each night Attend 12-step meetings in community where treated Access to AA/NA/CA/CMA Identify sponsor Some concern anonymity Some concern stigma Access mass transportation Family involved in SUD tx Residential tx ~ 4 weeks Attend 12-step meetings in Omaha, Lincoln, GI Some access to AA Less likely identify sponsor Greater concern anonymity Greater concern stigma No mass transportation Lack family involvement SUD tx

23. Intensive Referral Intervention to Improve SUD Treatment Outcomes among Rural and Highly Rural Veterans Funded by VA Office of Rural Health to modify IRI for rural veterans “Drug-related” meetings Anonymity Distance & transportation Added family involvement to intervention 2/17/2016

24. Training & Role Play Flowsheets Pamphlets & Journal Support Group Resources 2/17/2016

25. Intensive Referral Intervention Session I (group/individual) Review history with 12-Step groups Brief introduction to self-help groups (Pamphlet #1) Identify meetings they can attend Explain Self-Help Journal Identify liaison ***** Encourage patiet to introduce themselves, record name & phone # of one person at meeting Encourage patient to sign ROI for family/friend Contact & educate family/friend by phone (Pamphlet #5) 2/17/2016

26. 3-SESSION INTENSIVE REFERRAL INTERVENTION Session #1 Group or Individual 2/17/2016 3:17 AM STEP 3: SCHEDULING  Have clients sign a Release of Information for a supportive family member/significant other/friend.  Schedule the next session and record it in Self Help Journal. Then end session with client.  Following the session, contact the supportive person. If contacted, review Pamphlet #5, Self Help Groups: Family and Friends of Veterans Seeking Recovery and mail a copy to them. STEP 1: INTRODUCING  Determine clients’ histories with 12-Step groups.  Identify clients who have and have not have attended meetings in the past.  Provide and review Pamphlet #1, Self Help Groups: A Brief Introduction, discussing the benefits and barriers to attending 12-Step meetings and to becoming a member of a 12-Step group. STEP 2: PLANNING  Give clients a list of community AA/NA/CA/CMA meetings in or near their hometown.  Ask clients to identify at least one meeting they will attend before the next session.  Explain the Self Help Journal, asking clients to write down the meeting they will attend.  Encourage clients to introduce themselves to at least one person at the meeting they attend.  Ask clients to record in their journal the name and phone number of one member (liaison) they meet at the meeting they attend.

27. Intensive Referral Intervention Session 2 (group/individual) Verify meeting attendance Review Pamphlet #2 on attending 12-step meeting Identify a liaison to attend next meeting with patient***** Call during session #2 if no previous contact with liaison Discuss support from family/friend 2/17/2016

28. Session #2 Individual 2/17/2016 3:17 AM STEP 5: SCHEDULING  Discuss whether client is receiving support from family, friend, or significant other..  If client did not sign ROI to supportive family member/significant other/friend in session 1 discuss with client signing an ROI at this session.  Schedule the next session and record it in Self Help Journal. Then end session with client.  If session 3 is to be done by phone give pamphlets 3 & 4 to client. Then end session with client.  If previously unable to reach supportive person, try phoning again. If contacted, review Pamphlet #5, Self Help Groups: Family and Friends of Veterans Seeking Recovery and mail a copy to them. Client did contact liaison between sessions. Client did not contact liaison between sessions. Client did not attend meeting(s). Client did attend meeting(s). STEP 4: DISCUSSING LACK OF CONTACT  Counselor & client determine whether a liaison is available for the meeting(s) the client will attend.  If so, client tries to contact the liaison right then and arrange to attend a specific meeting together.  If not, counselor identifies a liaison or instructs client to attend a meeting and identify a liaison. STEP 4: DISCUSSING CONTACT  Ensure liaison contact information is recorded in Self Help Journal and in client’s phone.  Discuss whether client is seeking or finding a potential sponsor. STEP 2: DISCUSSING NON-ATTENDANCE  Discuss reasons for not attending meetings  Review Pamphlet #1 and emphasize attendance.  Identify meeting(s) to attend before next session. STEP 2: DISCUSSING ATTENDANCE  Congratulate client on meeting attendance.  Using Self Help Journal, discuss the meeting(s).  Identify meeting(s) to attend before next session. STEP 3: CHECKING LIAISON CONTACT  Provide and review Pamphlet #2, Self Help Groups: Going to 12-Step Meetings.  Ask if the client identified a 12-Step member liaison and contacted that liaison since the last session. STEP 1: CHECKING ATTENDANCE  Ask if the client attended one or more meetings since the last session.

29. Intensive Referral Intervention Session 3 (group/individual/phone) Verify meeting attendance Review barriers to meeting attendance (Pamphlet #3) and participation (Pamphlet #4) Determine if contact made with liaison & can contact during session Discuss support from family/friend 2/17/2016

30. Session #3 Group, Individual, or Phone 2/17/2016 3:17 AM Address client(s) who did attend. Address client(s) who did contact a liaison.Address client(s) who did not contact a liaison. STEP 1: CHECKING ATTENDANCE  Ask if client(s) attended one or more meetings since the last session. STEP 2: DISCUSSING ATTENDANCE  Congratulate client(s) on meeting attendance.  Using Self Help Journal, discuss the meeting(s).  Identify regular meeting(s) to attend in future. STEP 2: DISCUSSING LACK OF ATTENDANCE  Discuss reasons for not attending meetings  Mention higher relapse rate among non-attenders.  Identify regular meeting(s) to attend in future. Address client(s) who did not attend meeting(s). STEP 3: CHECKING LIAISON CONTACT  Provide and review Pamphlet #3, Self Help Groups: Problems and Solutions.  Provide and review Pamphlet #4, Self Help Groups: Participation.  Ask if the client identified a 12-Step member liaison and contacted that liaison since the last session. STEP 4: DISCUSSING CONTACT  Ensure liaison contact information is recorded in Self Help Journal and in client’s phone.  Discuss whether client is seeking or finding a potential sponsor. STEP 4: DISCUSSING LACK OF CONTACT  Counselor & client determine whether a liaison is available for the meeting(s) the client will attend.  If so, client tries to contact the liaison right then and arrange to attend a specific meeting together.  If not, counselor identifies a liaison or instructs client to attend a meeting and identify a liaison. STEP 5: DISCUSSING SUPPORT  Discuss whether client(s) is/are receiving support from family, friend, or significant other, and end session.  If previously unable to reach supportive person, try phoning again. If contacted, review Pamphlet #5, Self Help Groups: Family and Friends of Veterans Seeking Recovery and mail a copy to them.

31. Questions? 2/17/2016

32. References 1 “Encouraging Posttreatment Self-Help Group Involvement to Reduce Demand for Continuing Care Services: Two-year Clinical and Utilization Outcomes,” Humphreys & Moos, Alcoholism: Clinical and Experimental Research, 31 (1), 64-68, 2007. 2 “Attendance at Narcotics Anonymous and Alcoholics Anonymous meetings, frequency of attendance and substance use outcomes after residential treatment for drug dependence: a 5-year follow-up study,” Gossop, Steward & Marsden, Addiction, 103, 119-125, 2007.

33. 3 “A randomized controlled trial of intensive referral to 12- step self-help groups: One-year outcomes,” Timko and DeBenedetti, Drug and Alcohol Dependence, 90, 270-279, 2007. 4 “Intensive referral to 12-step dual-focused mutual-help groups,” Timko, Sutkowi, Cronkite, Makin-Byrd, Moos, Drug and Alcohol Dependence, 118, 194-201, 2011.

34. Thank You Department of Veterans Affairs Office of Rural Health Veterans Rural Health Resource Center Iowa City VA & Substance Use Disorders Quality Enhancement Research Initiative 2/17/2016