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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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Title&Below&please&list&the&title&of&this&resource.& &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
!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©&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
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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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
Mutual-help organizations
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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
Mutual-help organizations
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
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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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)
(Humphreys & Moos (2001) Alcoholism: Clinical Experimental Research)
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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
(Humphreys & Moos (2007) Alcoholism: Clinical Experimental Research)
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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
(Humphreys & Moos (2007) Alcoholism: Clinical Experimental Research)
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
Background and Context
Rationale and Conceptualization: Addiction Recovery
Management
Mutual-help organizations
The role of mutual-help organizations in recovery
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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