Self-Help MGH Substance Use Disorders: A comprehensive Update, Orlando, 2016

Transcription

1 Self-Help John F. Kelly, Ph.D. Elizabeth R. Spallin Associate Professor in Psychiatry Harvard Medical School Director Recovery Research Institute Program Director Addiction Recovery Management Service Associate Director MGH Center for Addiction Medicine MGH Substance Use Disorders: A comprehensive Update, Orlando, 2016

2 Disclosures Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest to disclose.

3 Overview 1. Background and Rationale: Why selfhelp ( mutual-help )? 2. Efficacy and Mechanisms: Do groups like AA confer real benefits? If so, how? 3. Clinical Interventions: What can we do clinically to enhance self-help participation and enhance outcomes?

4 Overview 1. Background and Rationale: Why selfhelp ( mutual-help )? 2. Efficacy and Mechanisms: Do groups like AA confer real benefits? If so, how? 3. Clinical Interventions: What can we do clinically to enhance self-help participation and enhance outcomes?

5 1. Why Self-help? Key Points Achieving stabilization and recovery is stressful Addiction is susceptible to relapse over the longterm MHOs like AA are widely available - provide adaptive long-term indigenous community recovery support for free

6 CBT MI TSF

7 Key: PFC prefrontal cortex; ACG anterior cingulate gyrus; OFC orbitofrontal cortex; SCC subcallosal cortex; NAc nucleus accumbens; VP ventral pallidum; Hipp hippocampus; Amyg amygdala. 7

8 8

9 Protracted/post-acute withdrawal effects: More stress and lowered ability to experience normal pleasures Increased sensitivity to stress via Increased activity in hypothalamic-pituitaryadrenal axis (HPA-axis) and CRF/Cortisol release Lowered ability to experience normal levels of reward via Down-regulated dopamine D2 receptor activity increasing risk of protracted dysphoria/anhedonia

10 For more severely dependent individuals course of dependence and achievement of stable recovery can take a long time Addiction Onset Help Seeking Full Sustained Remission (1 year abstinent) Relapse Risk drops below 15% 4-5 years 8 years 5 years Opportunity for earlier detection through screening in non-specialty settings like primary care/ed Selfinitiated cessation attempts 4-5 Treatment episodes/ mutualhelp Continuing care/ mutualhelp 60% of individuals with addiction will achieve full sustained remission (White, 2013)

11 Potential Advantages of Community Mutual-help Cost-effective -free; attend as intensively, as long as desired Focused on addiction recovery over the long haul Widely available, easily accessible, flexible Access to fellowship/broad support network Entry threshold (no paperwork, insurance); anonymous (stigma) Adaptive community based system that is responsive to undulating relapse risk

12 Substance Focused Mutual-help Groups Name Year of Origin Number of groups in U.S. Location of groups in U.S. Evidence base* (0-3) Alcoholics Anonymous (AA) 1935 Narcotics Anonymous (NA) 1940s Cocaine Anonymous (CA) 1982 Methadone Anonymous (MA) 1990s Marijuana Anonymous (MA) 1989 Rational Recovery (RR) ,651 Approx. 15,000 Approx groups Approx. 100 groups Approx. 200 groups No group meetings or mutual helping; emphasis is on individual control and responsibility all 50 States 1, 2, 3 all 50 States 1, 2 most States; 6 online meetings at 25 States; online meetings at 24 States; online meetings at 0 1, , 2 0 Self-Management and Recovery Training (S.M.A.R.T. Recovery) 1994 Approx. 250 groups 40 States; 19 online meetings at 1, 3 Secular Organization for Sobriety, a.k.a. Save Ourselves (SOS) 1986 Approx. 480 groups all 50 States; Online chat at 1 Women for Sobriety (WFS) groups Online meetings at WomenforSobriety 1 Moderation Management (MM) 1994 Approx.16 face-to-face meetings 12 States; Most meetings are online at 1 *0= None 1=Descriptive studies only 2 = Observational (correlational, longitudinal) 3= Experimental (random assignment, controlled). Source: Kelly & Yeterian, 2008

13

14 Overview 1. Background and Rationale: Why selfhelp ( mutual-help )? 2. Efficacy and Mechanisms: Do groups like AA confer real benefits? If so, how? 3. Clinical Interventions: What can we do clinically to enhance self-help participation and enhance outcomes?

15 2. Do groups like AA actually confer real benefits? If so, how? Key Points MHOs, like AA, confer benefits that are on par in magnitude with professional interventions Interventions that promote MHO participation (i.e., TSF) often produce superior outcomes and higher rates of FSR Participation in MHOs reduces reliance on professional care, reduces health costs and enhances remission TSF/MHOs produce these better outcomes because they mobilize mechanisms mobilized by formal treatment (e.g., coping skills/motivation/abstinence self-efficacy)

16

17 T S F O T H TSF Delivery Modes Stand alone Independent therapy Integrated into an existing therapy Component of a treatment package (e.g., an additional group) As Modular appendage linkage component In past 25 years, AA research has gone from contemporaneous correlational research to rigorous RCTs and

18 (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 and lagged moderated multiple mediation studies to elucidate its impact and MOBCs 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 importance of the mechanisms of behavior change within Alcoholics Anonymous: A multiple mediator analysis. Addiction 107(2):289-99

19 T S F O T H TSF Delivery Modes Stand alone Independent therapy Integrated into an existing therapy Component of a treatment package (e.g., an additional group) As Modular appendage linkage component

20 TSF often produces significantly better outcomes relative to active comparison conditions (e.g., CBT) Although TSF is not AA, it s beneficial effect is explained by AA involvement post-treatment.

21 Also, state of the art instrumental variables analyses, as well as propensity score matching (Ye and Kaskutas, 2013) that help to remove selfselection biases, indicate AA has a causal impact on enhancing abstinence and remission rates.

22 % Participants % Participants Linkage to AA can lead to much higher rates of full sustained remission (Project MATCH, 1997) TSF treatment can lead to much higher rates of full sustained remission Continuous Abstinence Rates during year following treatment (4-15 Months) Continuous Abstinence Rates past 90 days- 3 Years TSF TSF CBT CBT MET MET 10 Treamtment Condition 10 Treamtment Condition

23

24 HEALTH CARE COST OFFSET CBT VS 12-STEP RESIDENTIAL TREATMENT $20,000 $18,000 $17,864 $16,000 $14,000 $12,129 $12,000 $10,000 $8,000 $5,735 $6,000 $4,000 $2,000 $0 CBT Humphrey and Moos, 2001, 2007 ; ACER $9,840 $7,400 $2,440 TSF Compared to CBT-treated patients, 12-step treated patients more likely to be abstinent, at a $8,000 lower cost per pt over 2 yrs ($10M total savings) Year 1 Year 2 Total Also, higher remission rates, means decreased disease and deaths, increased quality of life for sufferers and their families

25 Findings from meta-analyses Emrick et al studies. AA attendance and involvement modest beneficial effect on drinking behavior Tonigan et al., studies. Examined moderators of effectiveness (i.e. outpatient vs. inpatient; study quality) Studies generally, were methodological poor and underpowered Kownacki & Shadish, 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

26 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 Peer-led AA participation and TSF found to be as effective as other comparison professionally-delivered interventions to which it was compared

27 Overview 1. Background and Rationale: Why selfhelp ( mutual-help )? 2. Efficacy and Mechanisms: Do groups like AA confer real benefits? If so, how? 3. Clinical Interventions: What can we do clinically to enhance self-help participation and enhance outcomes?

28 Curative factors of group therapy and of MHOs? Universality Altruism Instillation of hope Imparting information Recapitulation of the primary family experience Development of socializing techniques Imitative behavior Cohesiveness Existential factors Catharsis Interpersonal learning Self-understanding (Yalom, 1995)

29 (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 importance of the mechanisms of behavior change within Alcoholics Anonymous: A multiple mediator analysis. Addiction 107(2):289-99

30 Do more and less severely alcohol dependent individuals benefit from AA in the same or different ways? Aftercare (PDA) SocNet: pro-drk. 24% SocNet: proabst. 16% Self-efficacy (NA) 5% Self-efficacy (Soc) 34% Spirit/Relig 23% Depression 3% effect of AA on alcohol use for AC was explained by social factors but also by S/R and through negative affect (DDD only) SocNet: pro-abst. 11% Aftercare (DDD) SocNet: pro-drk. 16% Self-efficacy (Soc) 21% Self-efficacy (NA) 20% Spirit/Relig 21% Depression 11% Self-efficacy (NA) 1% Outpatient (PDA) Depression 2% Spirit/Relig 6% Majority of effect of AA on alcohol use for OP was explained by social factors Self-efficacy (NA) 1% Outpatient (DDD) Depression 5% SocNet: pro-drk. 33% SocNet: proabst. 31% Self-efficacy (Soc) 27% SocNet: pro-drk. 29% SocNet: proabst. 17% Spirit/Relig 9% Self-efficacy (Soc) 39% Source: Kelly, Hoeppner, Stout, Pagano (2012), Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous: A multiple mediator analysis. Addiction 107(2):

31 Do men and women benefit from AA in the same ways? 31

32 Empirically-supported MOBCs through which AA confers benefit Social network Spirituality Social Abstinence self-efficacy Coping skills Recovery motivation Negative Affect Abstinence selfefficacy Psychological Well-being Impulsivity Craving

33 Implications of Findings from 25 yrs of AA Mechanisms Research Results suggest the way AA works has closer fit with pragmatic social, cognitive, behavioral experiences of how its members stay sober documented in its later publications (Living Sober, 1975) written when AA numbered >1 million men + women (half with 5+ yrs of sobriety) than with the Big Book (1935; 2001), based on less than 100 all White, male, severely addicted cases, most with short lengths of sobriety. Consequently, the purported spiritual awakening deemed necessary for recovery, may have been true based on experience of initial very severe cases on which AA was based, and appears to be true of severe cases now, but the MOBC through which AA works has proven to be multifaceted

34 How might RSSs reduce relapse risk and aid recovery? Cue Induced Stress Induced Alcohol Induced CUES: -RSSs reduces relapse risks via social network changes that may reduce exposure to triggers and increase active coping and social ASE; MHOs may also reduce craving and impulsivity; STRESS: RSSs helps reduce stress induced relapse possibly via increased coping skills and spiritual Social framework and boosting negative affect ASE, particularly among women Psych ALCOHOL: RSSs may reduce alcohol induced relapse via Bio-Neuro reducing cravings, strong emphasis on abstinence (preventing priming dose exposure); boosting social and negative affect ASE RELAPSE RSS Kelly, JF Yeterian, JD In: McCrady and Epstein Addictions: A comprehensive Guidebook, Oxford University Press (2013) 34

35 Similar to the common finding that theoretically-distinct professional interventions do not result in differential patient outcomes, AA s effectiveness may not be due to its specific content or process. Rather, its chief strength may lie in its ability to provide free, long-term, easy access and exposure to recovery-related common therapeutic elements, the dose of which, can be adaptively selfregulated according to perceived need. (Kelly, Magill, Stout, 2009) Similar to psychotherapy literature rather than thinking about how AA or similar interventions work, better to think how individuals use or make these interventions work for them to meet most salient needs at any given phase of recovery

36 Does AA cause better outcomes or is AA participation an outcome of better prognosis? Using accepted scientific standards (Bradford Hill criteria) and the most rigorous scientific methods (i.e., RCTs, instrumental variables analysis, PS matching), evidence indicates causal therapeutic benefit of AA The one exception is specificity (e.g., other interventions could also cause these benefits) But given AA is available free of charge in practically every US community and that an intervention s Impact is a product of = reach x effectiveness (Glasgow et al, 2003), AA can be considered a clinical and public health ally in ameliorating the prodigious burden of disease attributable to alcohol addiction

37 Overview 1. Background and Rationale: Why selfhelp ( mutual-help )? 2. Efficacy and Mechanisms: Do groups like AA confer real benefits? If so, how? 3. Clinical Interventions: What can we do clinically to enhance self-help participation and enhance outcomes?

38 3. What can we do clinically to enhance self-help participation and thereby enhance clinical outcomes? Key points Broach the topic of MHO participation Discuss what to expect (if patient never been) Actively prescribe participation Link with active members whenever possible Monitor attendance and reaction

39 T S F O T H TSF Delivery Modes Stand alone Independent therapy Integrated into an existing therapy Component of a treatment package (e.g., an additional group) As Modular add-on linkage component

40 Strategies for Facilitating Outpatient Attendance of AA (Wallitzer et al, 2008) Approaches to assist in involvement in AA 169 adult alcoholic outpatients randomly assigned to one of three treatment conditions All clients received treatment that included: 12 sessions Focus on problem-solving, drink refusal, relaxation Recommendation to attend AA meetings

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

42 Strategies for Facilitating AA Attendance during Outpatient Treatment

43 Strategies for Facilitating AA Attendance during Outpatient Treatment

44

45

46 Summary 1. Background and Rationale: Why selfhelp ( mutual-help )? 2. Efficacy and Mechanisms: Do groups like AA confer real benefits? If so, how? 3. Clinical Interventions: What can we do clinically to enhance self-help participation and enhance outcomes?

47 Acknowledgements Colleagues Eden Evins, MD Bettina Hoeppner, PhD Brandon Bergman, PhD Post-Doc Fellows Allison Labbe, PhD Karen Urbanoski, PhD Corrie Vilsaint, PhD Interns David Eddie, MS Staff Julie Cristello, BA Sarah Dow, BS Nilo Fallah-Sohy, BS Claire Greene, MPH Veselina Hristova, MSW Nate Kelly, BA Julie Sloane, BA Jessica Kim, NP Erin Newman, LICSW Cristi O Connor, MHS Jonathan Watson, MA Julie Yeterian, MA Sources of Funding National Institute of Alcohol Abuse and Alcoholism/R21AA A1 National Institute of Mental Health/1R21MH A1 Recovery Research Institute, Private Donations National Institute of Alcohol Abuse and Alcoholism/R01AA A1 National Institute of Alcohol Abuse and Alcoholism/R01AA A1S1 Canadian Institute of Health Research/MOP National Institute of Alcohol Abuse and Alcoholism/K24AA Conflict of Interest None declared

48 Sign up for our free monthly Recovery Bulletin at: