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Where!Does!The!Data!Direct!Us?:!Addiction!Recovery!Management!and!the!Role!of!12:Step!Mutual!Help! Resources!

! Author&
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John!F.!Kelly,!Ph.!D.!!

! Citation& !
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.!
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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.!

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WHERE DOES THE DATA DIRECT US?

ADDICTION 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

OVERVIEW

Background and Context Rationale and Conceptualization: Addiction Recovery Management

Mutual-help organizations
The role of mutual-help organizations in recovery for young people

DRUG AND ALCOHOL CONCERNS

Public health
#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% $500 billion in US each year (lost productivity, criminal justice, medical costs) Excessive alcohol consumption costs society $2 per drink (CDC, 2011) 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
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

Financial Mortality
Prevention

ECONOMIC COSTS TO SOCIETY

$450 $400

$350

$300

$250
Economic cost (in billions)

$200

$150

$100

$50

$0 Alcohol and Illicit drugs Diabetes Obesity Smoking Heart disease

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

% USING PRIOR TO AGE 15

35% 30%

25%

20% % using

Alcohol use Marijuana

Cocaine
15% Hallucinogens

10%

5%

0% 1934-1944 1945-1955 1956-1960 1961-1965 1966-1970 1971-1975 1976-1980 1981-1985 1986-1990

Adapted from: Johnson and Gerstein (1998) Am Jnl Public Health, 88, 1, 27-33

% MEETING DSM-III-R LIFETIME ALCOHOL

DEPENDENCE CRITERIA
35%

30%

25%

20% Male (n=509) 15% Female (n=545)

10%

5%

0% 1910-1929 1930-1939 1940-1949 1950-1959 1960-1979

Birth Cohort 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.

SUBSTANCE USE DISORDERS (SUD) IN THE PAST YEAR AMONG PERSONS AGE 12 OR OLDER

SUBSTANCE USE AND PROBLEM ONSET AND OFFSET

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

100 90 80 70 60 50

Severity Category

No Alcohol or Drug Use

Light Alcohol Use Only Any Infrequent Drug Use Regular AOD Use Abuse Dependence 14-15 16-17 18-20 21-29 30-34 35-49 50-64 65+

40
30 20

10 0
12-13

NSDUH and Dennis & Scott

WHY DOES SUD ONSET IN YOUNG PEOPLE? DEVELOPMENTAL CONSIDERATIONS & RISKS

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

EMERGING ADULT CLINICAL DIFFERENCES

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)
C10H15N C9H13N

OVERVIEW

Background and Context Rationale and Conceptualization: Addiction Recovery Management

Mutual-help organizations
The role of mutual-help organizations in recovery for young people

RATIONALE FOR LONG-TERM RECOVERY 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)

WHY 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

CHRONIC NATURE OF SUBSTANCE DEPENDENCE MAKES IT WELLSUITED TO ONGOING RECOVERY MANAGEMENT (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 maintenance(White & Kelly, 2011).

SUPPORT SERVICES IN THE TREATMENT PROCESS

BI-AXIAL MODEL OF ADDICTION

Addiction severity

Substance-related problems
(physical and mental health; housing; social and family relations; education and employment)

Reciprocal: Increasing severity leads to more problems and more problems perpetuates continued use

Kelly et al, (under review)

BI-AXIAL MODEL OF RECOVERY

Addiction Remission

Recovery Capital
(physical and mental health; housing; social and family relations; education and employment)

Reciprocal: Increasing duration of remission leads to greater recovery capital BUT ALSO greater recovery Kelly et al, (under review) capital perpetuates continued remission

STRESS AND LIFE SATISFACTION AS A FUNCTION OF LENGTH OF RECOVERY (N = 354)

8.5

Mean (scale range = 0 to 10)

8.0

7.5

7.0

6.5

6.0

Overall life satisfaction Stress rating pst yr

5.5

5.0

>6 months Six to 18 mos

18 to 36 mos RECOVERY STAGE

3+ years

Source: Laudet et al., Alcoholism Treatment Quarterly, 24: , 33-74, 2006

WHAT ARE RECOVERY 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 Mutual-help organizations

Measurement and Data

HOW MIGHT RECOVERY SUPPORT SERVICES AID RECOVERY? INTRA-INDIVIDUAL MEDIATORS

Motivation Self-efficacy Coping Self-esteem/respect Hope/future orientation Spirituality/purpose/meani ng

Residential recovery homes Recovery community centers Peer-based recovery support Education-based recovery support Mutual-help organizations

Recovery maintenance

RECOVERY CONTEXTS: EDUCATION BASED RECOVERY

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, collegetested intelligence, current income and job status, health decline of innercity men who obtained a college education was same as Harvard sample Education represents important recovery capital for young people (Vaillant & Mukamal, 2001, Am. Jnl. Of Psychiatry

ASSOCIATION 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 collegessafe 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 extent and nature of benefits

TEXAS TECH UNIVERSITY: SINGLE GROUP PREPOST DESIGN

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

Source: Cleveland et al. (2007)

AUGSBURG COLLEGE STEPUP PROGRAM

Support groups and sobriety-specific houses Outcomes

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

RUTGERS RECOVERY HOUSE DATA 2008-2011

Annual avg relapse rate across 13 yrs = 6%

Source: Laitman & McLaughlin (2011)

EDUCATIONAL CONTEXT RECOVERY SUPPORT PROGRAMS: SUMMARY

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

OVERVIEW

Background and Context Rationale and Conceptualization: Addiction Recovery Management

Mutual-help organizations
The role of mutual-help organizations in recovery for young people

MUTUAL-HELP: IMPLICATIONS FOR ENHANCING RECOVERY AND CONTAINING COST

1.

- 5 THINGS WEVE LEARNED:

2.

3.

4.

5.

Mutual-help organizations help offset burden of disease from SUD Mutual-help groups confer clinically meaningful benefits for many different types of individuals above and beyond formal treatment services Mutual-help groups work through mechanisms similar to those operating in formal treatment Mutual-help group participation can reduce healthcare costs by reducing patients reliance on professional services without any detriment to outcomes, and actually enhance outcomes 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

MUTUAL HELP RESEARCH - RECENT HISTORY

Given public health significance, Institute of Medicine (IOM, 1990) called for AA research.
450

Number of Publications on AA and NA 1960-2010

400

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.

350
300 250 200 150 100 50 0 1960-70 1971-80 1981-90 1991-00 2001-10

FINDINGS 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

FERRI, AMATO, DAVOLI (2006) (COCHRANE REVIEW)

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 professionallydelivered interventions

FOR 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? 3. Women?

PSYCHIATRIC COMORBIDITY I.

SUDs frequently co-occur with psychiatric illnesses Concerns about membergroup fit of co-morbid with typical 12-step groups Barriers
Putative opposition to medications Clinical syndromes vs. not working the program

DUAL-DIAGNOSIS SUMMARY SHOULD 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)

RELIGIOUSNESS & 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.

RELIGIOUSNESS & 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

RELIGIOSITY SUMMARY & RECOMMENDATIONS:

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

WOMEN 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. - womenspecific issues more difficult to discuss.

WOMEN 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?

COST-EFFECTIVENESS (1)
90%
80% 70% 60% 50% CBT 40% 30% 20% 10% 0% Abstinent No SA-related problems No psychological problems No psychiatric problems TSF

(Humphreys & Moos (2001) Alcoholism: Clinical Experimental Research)

COST-EFFECTIVENESS (2)
18.0

16.0

14.0

12.0

10.0 CBT 8.0 TSF

6.0

4.0

2.0

0.0 12-step attendance Inpatient days Outpatient visits

(Humphreys & Moos (2001) Alcoholism: Clinical Experimental Research)

COST-EFFECTIVENESS II (1) 2YR FOLLOW-UP

90.0% 80.0% 70.0% 60.0% 50.0% 40.0% CBT 30.0% 20.0% TSF

10.0%
0.0% Abstinent No SA-related problems No psychological problems No psychiatric problems

(Humphreys & Moos (2007) Alcoholism: Clinical Experimental Research)

COST-EFFECTIVENESS II (2) 2YR FOLLOW-UP

12.0

10.0

8.0

6.0

CBT TSF

4.0

2.0

0.0 12-step attendance Inpatient days Outpatient visits

(Humphreys & Moos (2007) Alcoholism: Clinical Experimental Research)

HEALTH CARE COST OFFSET POTENTIAL OF MHGS (1) CBT VS 12-STEP RESIDENTIAL TREATMENT
Cost per patient over 1 year *
CBT Resulted in $4,729 greater costs per patient with sig. worse outcomes
Cost per patient over 1 year * $12,129.00

$7,400.00

CBT

TSF

CBT Resulted in $3,295 greater costs per patient with sig. worse outcomes in Yr 2 Follow up

Cost per patient over 1-2 year

Cost per patient $5,735.00

$2,440.00

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

SOURCE: HUMPHREYS & MOOS, 2001; 2007

CBT

TSF

How do Mutual help organizations like AA help individuals maintain recovery over time? What can such data tell us more broadly about recovery mechanisms?

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

Stress Induced
Social Psych

RELAPSE

Drug Induced
AA-related social network changes may help avoid cues, reduce and tolerate distress, and maintain abstinence minimizing drug-induced relapse risks

Neurobiology

AA

Kelly JF, Yeterian, JD, (In press). Mutual help groups. In McCrady and Epstein. Comprehensive Textbook on Substance Abuse.

(3-mo) AA attendance

(15-mo) Alcohol Outcomes (PDA or DDD)

Baseline (BL) Covariates Age Race Sex Marital Status Employment Status Prior Alcohol Treatment MATCH Treatment group MATCH study site Alcohol Outcomes (PDA/DDD) (BL) Self-efficacy Negative Affect (BL) Self-efficacy Positive Social (BL) Religious/Spiritual Practices (BL) Depression (BL) Social Network pro-abstinence (BL) Social Network pro-drinking (9-mo) Self-efficacy Negative Affect (9-mo) Self-efficacy Positive Social (9-mo) Religious/Spiritual Practices (9-mo) Depression (9-mo) Social Network pro-abstinence (9-mo) Social Network pro-drinking

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

RELATIVE UNIQUE CONTRIBUTION OF EACH MEDIATOR IN EXPLAINING AAS EFFECTS ON ALCOHOL

OUTCOMES

Aftercare (PDA)
Self-efficacy (NA) 5% Depression 3%

Aftercare (DDD)

SocNet: pro-drk. 24%

SocNet: pro-drk. 16% Spirit/Relig 23% SocNet: pro-abst. 11%

Self-efficacy (NA) 20% Depression 11%

SocNet: proabst. 16%

Self-efficacy (Soc) 34%

Self-efficacy (Soc) 21%

Spirit/Relig 21%

Outpatient (PDA)
Self-efficacy (NA) 1% Depression Spirit/Relig 2% 6%

Outpatient (DDD)
Self-efficacy (NA) 1% Depression 5%

SocNet: pro-drk. 33%

Self-efficacy (Soc) 27%

SocNet: pro-drk. 29%

Spirit/Relig 9%

SocNet: proabst. 31%

SocNet: proabst. 17%

Self-efficacy (Soc) 39%

51

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

RELATIVE UNIQUE CONTRIBUTION OF EACH MEDIATOR IN EXPLAINING AAS EFFECTS ON ALCOHOL

OUTCOMES

Aftercare (PDA)
Self-efficacy (NA) 5% Depression 3%

Aftercare (DDD)

SocNet: pro-drk. 24%

SocNet: pro-drk. 16% Spirit/Relig 23%

SocNet: proabst. 16%

Self-efficacy (Soc) 34%

Outpatient (PDA)
Self-efficacy (NA) 1% Depression Spirit/Relig 2% 6%

SocNet: pro-drk. 33%

Self-efficacy (Soc) 27%

SocNet: proabst. 31%

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

SocNet: pro-abst. 11%

Self-efficacy (NA) 20% Depression 11%

Self-efficacy (Soc) 21%

Spirit/Relig 21%

Outpatient (DDD)
Self-efficacy (NA) 1% Depression 5%

SocNet: pro-drk. 29%

Spirit/Relig 9%

SocNet: proabst. 17%

Self-efficacy (Soc) 39%

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

AA ATTENDANCE AND THE % CHANGE IN BOTH PRO-ABSTINENT AND PRO-DRINKING NETWORK TIES FROM TREATMENT INTAKE TO THE 9-M (OP SAMPLE)

Source: Kelly et al, 2011, Drug and Alcohol Dependence

AA ATTENDANCE AND THE % CHANGE IN BOTH PRO-ABSTINENT AND PRO-DRINKING NETWORK TIES FROM TREATMENT INTAKE TO THE 9-M (AC SAMPLE)

Source: Kelly et al, 2011, Drug and Alcohol Dependence

T S F

O T H

TSF DELIVERY MODES

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

Stand alone Independent therapy

Integrated into an existing therapy

e.g., Project MATCH Research Group (1997); Litt et al, (2009)

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

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

As Modular appendage linkage component

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

OVERVIEW

Background and Context Rationale and Conceptualization: Addiction Recovery Management

Mutual-help organizations
The role of mutual-help organizations in recovery for young people

WHAT ABOUT YOUTH? POTENTIAL DEVELOPMENTAL BARRIERS:

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 abstinence and spiritual growth

YOUTH-SPECIFIC AA/NA OUTCOMES KNOWLEDGE:

Authors Alford, Koehler, Leonard Brown Kennedy & Minami Hsieh, Hoffman, Hollister Kelly, Myers, Brown Kelly, Myers, Brown Mason and Luckey Year 1991 N 157 Follow-up (Months) 6, 12, 24 % Female 38% M Age 16 Setting (No. of sites) Inpatient (1)

1993
1993 1998 2000 2002

140
91 2,317 99 74

12
12 6, 12 6 6

42%
23% 35% 60% 62%

16
16.5 17-19 16 16

Inpatient (2)
Inpatient (1) Inpatient (24) Inpatient (2) Inpatient (2)

2003
2004 2005 2008 2009 2010 In press In press 2012

95
810 74 160 419 127 419 127 303

3, 12
12 6 6, 12, 24, 48, 72, 96 6, 12, 36 3, 6 12, 36, 60, 72, 84 3, 6, 12 1, 3, 6, 12

32%
30% 62% 34% 34% 24% 34% 24% 27%

22
16 16 13-18 13-18 16.7 13-18 16.7 20

Inpatient (2)
Residential (8),STI (6), Outpatient (9) Inpatient (2) Intensive outpatient (4) Intensive outpatient (4) Outpatient (1) Intensive outpatient(4) Outpatient (1) Residential (1)

Grella, Joshi, Hser

Kelly, Myers, Brown Kelly, Brown et al Chi, Kaskutas, Sterling et al Kelly, Dow, Yeterian Chi, Sterling, Campbell, Weisner

Kelly and Urbanoski

Kelly, Stout, Slaymaker

RESULTS: RATES OF ATTENDANCE

Any, Monthy, and Weekly AA/NA Attendance across 8 Years Following Inpatient Treatment 100% 90% 80%
% Attending AA/NA

70% 60% 50% 40% 30% 20% 10% 0% 0-6m 6m-1yr 1-2yr 2-4yr 4-6yr 6-8yr Follow-Up

Any Monthly Weekly

Source: Kelly, J.F., Brown, S. A., Abrantes, A., Kahler, C. H., & Myers, M. (2008)

8 Year follow-up across young adulthood : Trajectory Outcome Group attending AA/NA at least Weekly
Abstainers Infrequent User worse with time

100 % Attending AA/NA weekly 90 80 70 60 50 40 30 20 10 0 6m 12m 24m 48m 72m 96m

Frequent User

Time

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.

LAGGED GEE MODEL OF YOUTH TREATMENT OUTCOME IN RELATION TO AA/NA ATTENDANCE OVER 8 YEARS
Parameter Estimate Standard Error 95% Confidence Limits 23.6656 -0.2614 -14.5526 -0.1772 -3.7722 -0.5761 -0.8727 1.0674 0.4304 50.9486 3.1462 -4.1234 0.0150 0.0090 1.4460 12.0065 2.8360 0.5757 Z P

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

37.3071 1.4424 -9.3380 -0.0811 -1.8816 0.4349 5.5669 1.9517 0.5030

6.9601 0.8693 2.6605 0.0490 0.9646 0.5158 3.2856 0.4512 0.0371

5.36 1.66 -3.51 -1.65 -1.95 0.84 1.69 4.33 13.56

<.0001 0.0971 0.0004 0.0980 0.0511 0.3991 0.0902 <.0001 <.0001

Time Gender Pre-treatment PDA Moderate use Aftercare1 6m Formal Treatment2 AA/NA2 PDA2

1= Sq root transformed; 2= Time varying covariate

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

EMERGING 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

Source: Kelly, Stout, Slaymaker (2012)

AA/NA ATTENDANCE ACROSS TIME

100%

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

10%
0% Pre-tx 1m post-tx 3m post-tx 6m post-tx 12m post-tx

Source: Kelly, Stout, Slaymaker (2012)

HAVING AN AA/NA SPONSOR ACROSS TIME

60%
50% 40% 30%

20%
10% 0%

Pre-tx

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

Source: Kelly, Stout, Slaymaker (2012)

SUBSTANCE 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

Incremental benefits of select aspects of 12step involvement

67

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

WITHIN-PERSON CHANGE IN PDA FOR DISCRETE SUB-GROUPS OF AA/NA ATTENDEES FOLLOWING OUTPATIENT SUD TREATMENT (N=111)
90 80 70 60 50 40 30 20 10 0 Admission 3 months 6 months 12 months
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.
12-step attendance after admission:

None (n=61) Inconsistent (n=43) Weekly (n=7)

Moderators: Might Age Composition of AA/NA meetings moderate participation and derived benefits? 100
95 90 85 80 75 70 65 60 55 50
All adults Mostly adults Even mix Mostly teens All teens

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.

STATE OF THE SCIENCE OF PEER-BASED MUTUALHELP FOR YOUNG PEOPLE

All studies correlational/observational (self-selection); varying degrees of scientific rigor to help rule out selfselection 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)

SUMMARY

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

ACKNOWLEDGEMENTS

Special thanks to Veselina Hristova, BA, for her help in preparing this presentation. Thank you for your attention!