Where Does The Data Direct Us?: Addiction Recovery Management and the Role of 12-‐Step Mutual Help...

7/31/2019 Where Does The Data Direct Us?: Addiction Recovery Management and the Role of 12- Step Mutual Help Resources

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

12Step"Mutual"Help"Resources."[PowerPoint!Slides].!Proceedings!from!the!3 rd!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 mutualhelp


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management the rationale and conceptualization of addiction recovery management discusses mutualhelp

WHEREDOESTHEDATADIRECTUS?

ADDICTIONRECOVERYMANAGEMENT

ANDTHEROLEOF 12-STEPMUTUAL

HELPRESOURCES

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


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Mankind, ever in pursuit of pleasure,

have reluctantly admitted into the

catalogue of their diseases, those evilswhich were the immediate offspring of

their luxuries

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


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OVERVIEW

Background and Context

Rationale and Conceptualization: Addiction Recovery

Management

Mutual-help organizations

The role of mutual-help organizations in recovery

for young people


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DRUGAND ALCOHOL CONCERNS#1 public health problem (Institute for Health

Policy, 2001; CASA, 2011)

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

Publichealth

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

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

Financial

SUD leading cause of mortality - alcoholleading risk factor among males 15-59

worldwide Opiate overdose2nd leading cause of

accidental death nationwide; 1st in 17 statesMortality

Onset of long-term problems occur duringadolescence/young adulthood

90% adults with dependence start using beforeage 18

50% of adults start using before age 15

Prevention


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ECONOMICCOSTSTOSOCIETY

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

Economic cost (in billions)


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% USINGPRIORTOAGE 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

sing Alcohol use

Marijuana

Cocaine

Hallucinogens

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


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% MEETING DSM-III-R LIFETIMEALCOHOL

DEPENDENCECRITERIA

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


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SUBSTANCE USE DISORDERS (SUD) INTHE PAST

YEAR AMONG PERSONS AGE 12 OR OLDER


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SUBSTANCE USEAND PROBLEM ONSETAND

OFFSET

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

Severity Category


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WHYDOES SUD ONSETINYOUNGPEOPLE?

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 inperceived controland 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 withincongruency between subjective perceptions and objective realitycreates new risks & challenges particularly regarding alcohol/drugs


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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 thaneither 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


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OVERVIEW



Management



for young people


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RATIONALEFOR LONG-TERM RECOVERYMANAGEMENT

Minority seek addiction care (SAMHSA, 2010;Dawson et al, 2005); tx-seekers typically moresevere/complex

Chronic relapsing nature of addiction

requires a continuing care approach for those whoseek care, akin to management of other chronicillnesses (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 reduceexpensive medicalcare (hospitalization)


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WHYARERECOVERYSUPPORTSERVICES

IMPORTANT?

Among treatment seekers psychiatric, medical, legal,education, employment, and family problems common(Davidson et al, 2010)impede effectiveness ofpurely addiction-focused clinical efforts

Adding more addiction focused sessions within a brieftime period does not improve outcomes (e.g., ProjectMATCH, 1997; CYT; Dennis et al, 2004)

but, adding recovery support services and

community mutual-help facilitation can enhance andsustain tx gains (Boisvert et al, 2008; Kelly andYeterian, 2011; McLellan et al, 1998; Milby et al, 1996;Rowe et al, 2007) adding to individuals recoverycapital


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CHRONICNATUREOFSUBSTANCEDEPENDENCEMAKESITWELL-

SUITEDTOONGOING RECOVERYMANAGEMENT (RM)

APPROACHES

Addiction talked as chronic but stilltreated as acute condition:

Serial episodes of self-contained and

unlinked intervention

Implicit expectation that a lifelong cure

will occur following a single episode ofrehab

Continuing care (aftercare) as

afterthought

Recovery management is a philosophy of

organizing addiction treatment andrecovery support services to enhance early

pre-recovery engagement, recovery

initiation, long-term recovery

maintenance(White & Kelly, 2011).

SUPPORT SERVICES IN THE TREATMENT


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SUPPORT SERVICESINTHE TREATMENT

PROCESS


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BI-AXIALMODELOF ADDICTION

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 problemsperpetuates continued use


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BI-AXIALMODELOFRECOVERY

AddictionRemission

Recovery Capital(physical and mental health; housing; socialand family relations; education and

employment)

Kelly et al, (under review)

Reciprocal: Increasing duration of remission leads

to greater recovery capital BUT ALSO greater recoverycapital perpetuates continued remission


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STRESSAND LIFE SATISFACTIONASAFUNCTION

OF LENGTHOF RECOVERY(N = 354)

RECOVERY STAGE

3+ years

18 to 36 mos

Six to 18 mos

>6 months

Mean(scalerange

=0to10)

8.5

8.0

7.5

7.0

6.5

6.0

5.5

5.0

Overall life

satisfaction

Stress rating pst yr

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


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WHATARE RECOVERYSUPPORTSERVICES?

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

Recovery community centers (RCCs)

Peer-based Recovery support

Education-based recovery support: high schooland college based recovery support for young

people



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Measurement and Data


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HOWMIGHT RECOVERYSUPPORT SERVICESAID

RECOVERY?

INTRA-INDIVIDUAL MEDIATORS

Residential recovery homes

Recovery community centersPeer-based recovery support

Education-based recovery

support


Motivation

Self-efficacy

Coping

Self-esteem/respect

Hope/future orientation

Spirituality/purpose/meani

ng

Recovery maintenance


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RECOVERYCONTEXTS: EDUCATION BASED RECOVERY

SUPPORTS

College education

trumped money andsocial prestige as the

pathway to health and

happiness (Vaillant, 2011)

Despite big differences

between core city sampleand Harvard sample in

parental social class, college-

tested intelligence, current

income and job status,

health decline of inner-

city men who obtained acollege education was

same as Harvard sample

Education represents

important recovery

capital for young people(Vaillant & Mukamal, 2001, Am. Jnl. Of Psychiatry


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ASSOCIATIONOFRECOVERYSCHOOLS

Despite education being important to long term health andwell-being, college environment is recovery unfriendly -activities organized around alcohol/parties limiting socialoptions; 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 withrecovery and continuing care, but they are not treatmentcenters

No experimental/comparative effectiveness trials to estimateextent and nature of benefits


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TEXAS TECH UNIVERSITY: SINGLEGROUP PRE-

POST 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)


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AUGSBURG COLLEGE

STEPUPPROGRAM

Support groups and sobriety-specific houses Outcomes Annual

avg relapse

rate

across

13 yrs = 13%,

Down to abou7% in recent


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RUTGERS RECOVERYHOUSEDATA

2008-2011

Source: Laitman & McLaughlin (2011)

Annual

avg relapse

rate

across

13 yrs = 6%


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EDUCATIONALCONTEXTRECOVERYSUPPORT

PROGRAMS: SUMMARY

Programs are catching on rapidly in collegesettings

Make return to college more attractive and

increases access; can have life-long ramifications

High retention, low relapse rates, and highacademic achievement

Comparative investigations lackingwouldinform the nature, content, and intensity ofsupport


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OVERVIEW



Management



for young people


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MUTUAL-HELP: IMPLICATIONSFORENHANCINGRECOVERY

ANDCONTAININGCOST - 5 THINGSWEVELEARNED:

1. Mutual-help organizations help offset burden of diseasefrom 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 tothose 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

outcomes5. 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 andimplications for cost containment under health care reform. Substance Abuse


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MUTUALHELP RESEARCH - RECENT HISTORY

Given public health

significance, Institute ofMedicine (IOM, 1990)

called for AA research.

state of science summarized

and further researchopportunities outlined

(McCrady and Miller, 1993)

Past 20 yrs significant

increase in scientificinterest 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


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FINDINGSFROMMETA-ANALYSES

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

Tonigan et al., 1996 - 74 studies. Examined moderators ofeffectiveness (i.e. outpatient vs. inpatient; study quality)

Studies generally, were methodological poor and underpowered

Kownacki & Shadish, 199921 studies. Examined controlled trialsonly

- Randomization confounded with coerced status (justice systemrequired)

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

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

- Found support for 12-step-based tx and non-coerced AAattendance


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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 professionally-

delivered interventions


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FORWHOMAREMUTUAL-HELPGROUPS

PARTICULARLYHELPFUL / NOTHELPFUL?

Clinical concerns member-group fit with 12-stepmutual-help organizations.

1. Dual-diagnosed (DD)?

2. Non-religious people?

3. Women?


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PSYCHIATRIC COMORBIDITYI.

SUDs frequently co-occur

with psychiatric illnesses

Concerns about member-group fit of co-morbid with

typical 12-step groups

Barriers

Putative opposition tomedications

Clinical syndromes vs. notworking the program


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DUAL-DIAGNOSIS SUMMARY

SHOULD DD PATIENTSBEREFERREDTO AA/NA?

Attendance rates may be similar and many maybenefit (e.g. PTSD)

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

have more difficulty

Attendance rates may be similar but co-morbidmay require additional/more specific supportand/or greater facilitation (e.g. severe MDD)


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RELIGIOUSNESS & 12-STEPMUTUAL-HELP

Concerns about quasi-religious concepts

Implications for non-religious individuals

Referral to 12-step organizations should takeinto account religious background.

Practice guidelines of APA, recommend

clinicians refrain from referring nonreligiouspeople to 12-step.


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RELIGIOUSNESS & 12-STEPMUTUAL-HELP

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

veterans) Belief in God did not relate to attendance

People lower in recent religious practices attended lessfrequently

Degree of religiosity did not affect salutary relationship

between AA/NA and substance use outcomes at 1 and3yrs (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


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RELIGIOSITYSUMMARY& 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 mediatedbenefits (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


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WOMENANDMUTUAL-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. - women-

specific issues more difficult to discuss.


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WOMENANDMUTUAL-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


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Given health care burden ofSUD, can Mutual-help group

participation reducehealthcare costs by reducing

patients reliance on

professional services andproduce better outcomes?


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COST-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

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


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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

COST-EFFECTIVENESS (2)



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

problems

No psychiatric

problems

CBT

TSF



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

0.0

2.0

4.0

6.0

8.0

10.0

12.0

12-step attendance Inpatient days Outpatient visits

CBT

TSF


HEALTH CARE COST OFFSET POTENTIAL OF MHGS (1)


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$12,129.00

$7,400.00

CBT TSF

Cost per patient over 1 year *

Cost per patient over 1 year *

HEALTH CARECOSTOFFSETPOTENTIALOF MHGS (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 patientCBT 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


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How do Mutual helporganizations like AA help

individuals maintain recovery

over time?

What can such data tell us more

broadly about recoverymechanisms?

How might MHGs like AA reduce relapse risk and sustain the


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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 changesmay help avoid cues, reduce and

tolerate distress, and maintain

abstinence minimizing drug-induced

relapse risksAA

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


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(9-mo) Self-efficacyNegative Affect

Baseline (BL) CovariatesAge

RaceSex

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-efficacyNegative Affect

(9-mo) Self-efficacyPositive Social

(BL) Self-efficacyPositive Social

(9-mo) Religious/SpiritualPractices

(BL) Religious/SpiritualPractices

(9-mo) Depression(BL) Depression

(9-mo) Social Networkpro-abstinence

(BL) Social Networkpro-abstinence

(9-mo) Social Networkpro-drinking

(BL) Social Networkpro-drinking

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

RELATIVEUNIQUE CONTRIBUTIONOFEACHMEDIATORINEXPLAININGAASEFFECTSONALCOHOL

OUTCOMES


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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,

Addiction

RELATIVEUNIQUE CONTRIBUTIONOFEACHMEDIATORINEXPLAININGAASEFFECTSONALCOHOL

OUTCOMES


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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 foryouth;

substance use

rising and

peaking in

emerging

adulthood;common

precursor to

relpase


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AAATTENDANCEANDTHE % CHANGEINBOTHPRO-ABSTINENT

ANDPRO-DRINKINGNETWORKTIESFROMTREATMENTINTAKE

TOTHE 9-M (OP SAMPLE)

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


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AAATTENDANCEANDTHE % CHANGEINBOTHPRO-ABSTINENT

ANDPRO-DRINKINGNETWORKTIESFROMTREATMENTINTAKE

TOTHE 9-M (AC SAMPLE)

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

T O


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TSF DELIVERYMODES

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)


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OVERVIEW



Management



for young people

W Y ?


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WHATABOUT 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:

- Addictionseverity (withdrawal/consequences)

- Problem recognition/motivation for abstinence Life-Context Specific:

- Younger age relative to AA/NA members mismatch withlife-contextfactors (e.g., marriage, children, employmentproblems) /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 completeabstinence and spiritual growth


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YOUTH-SPECIFIC AA/NAOUTCOMES KNOWLEDGE:

Authors Year NFollow-up

(Months)% Female M Age

Setting

(No. of sites)

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

Brown1993 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 Luckey2003 95 3, 12 32% 22 Inpatient (2)

Grella, Joshi, Hser2004 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 UrbanoskiIn press 127 3, 6, 12 24% 16.7 Outpatient (1)

Kelly, Stout, Slaymaker 2012 303 1, 3, 6, 12 27% 20 Residential (1)

R R A


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RESULTS: RATESOF ATTENDANCE

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

ttendingAA/NA

Any

Monthly

Weekly

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

Following Inpatient Treatment

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


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0

10

20

30

40

50

60

70

80

90

100

6m 12m 24m 48m 72m 96m

%At

tendingAA/NAweekly

Time

8 Year follow-up across young adulthood : TrajectoryOutcome 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, 81468-1478.

LAGGED GEE MODEL OF YOUTH TREATMENT OUTCOME IN


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61

LAGGED GEE MODELOF YOUTH TREATMENT OUTCOMEIN

RELATIONTO AA/NAATTENDANCEOVER 8 YEARS

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


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EMERGINGADULTSAND AA: BENEFITSINTHE

YEARFOLLOWINGINPATIENTTREATMENT

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)


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AA/NAATTENDANCEACROSSTIME

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(2012)


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HAVINGAN AA/NASPONSORACROSSTIME

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)


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SUBSTANCEUSEOUTCOMESAND AA/NA

Controlling for substance use at treatmentintake, higher AA/NA attendance associated with

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

sps


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66

Incremental benefits of select aspects of 12


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67

Incremental benefits of select aspects of 12-

step involvement

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

WITHIN-PERSON CHANGE IN PDA FOR DISCRETE SUB-GROUPS


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WITHIN PERSONCHANGEIN PDAFORDISCRETESUB GROUPS

OF AA/NAATTENDEESFOLLOWINGOUTPATIENT SUD

TREATMENT (N=111)

0

1020

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 adolescentoutpatient outcomesAlcoholism: Clinical Experimental Research.

Moderators: Might Age Composition of AA/NA meetings moderate


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All teensMostly teensEven mixMostly adultsAll adults

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 attendanceand outcomes Journal of Child and Adolescent Chemical Dependency.

participation and derived benefits?

STATE OF THE SCIENCE OF PEER BASED MUTUAL


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STATEOFTHE SCIENCEOF PEER-BASED MUTUAL-

HELPFORYOUNGPEOPLE

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 amongyoung 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 amongoutpatients/CBT oriented programs

No experimental studies of TSF linkage strategies (one

underway)

Outcomes measured mostly restricted to alcohol/drug withlimited focus on other recovery outcomes (e.g., educationalattainment; absenteism; arrests; health)


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SUMMARY

Recovery support services provide meaningful indigenous help

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

Developmental milestones of education and training may be keyto long term recovery as well as physical and mental health

Few comparative studies examining the utility and impact ofrecovery support services (exception: recovery homes).

Peer-based mutual-help has increasing evidence for benefit of asimilar magnitude to adults

TSF is an empirically supported treatment for adults, butexperimental studies of MHG facilitation needed to evaluateamong young people

College recovery initiatives which often incorporate 12-step

philosophy, show great promise with high retention, low relapserates, and higher than average GPA, but await more rigorouscomparative evaluation


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ACKNOWLEDGEMENTS

Special thanks to Veselina Hristova, BA, for her

help in preparing this presentation.

Thank you for your attention!

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Where Does The Data Direct Us?: Addiction Recovery Management and the Role of 12-‐Step Mutual Help...

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