A Transatlantic Perspective on
Recovery from Addiction
Annual Lecture of The Welsh Council on Alcohol and Other Drugs
25 June 2013
Cardiff, Wales
Professor Keith Humphreys
Veterans Affairs and Stanford University Medical Centers, Palo Alto, California
And
Institute of Psychiatry and National Addiction Centre, King’s College London
Scope of Talk
I.
Public Policy Currents
II.
Scientific Evidence
III. Transatlantic observations
Public Policy Currents
Recovering Community Support
Programme
• 4-year grants given to 30 culturally, racially
and geographically diverse organisations
• Each organisation developed recovery
leadership capacity, advocated for better
treatment, engaged in public education and
provision of peer-designed recovery support
services
Access to Recovery
• Treated patients in early recovery given a
voucher for recovery-supportive
services/products
• Voucher gave recovering people more
power and choice
• Widened the number and diversity of
service providers
The 2005 Recovery Summit
• Convened by the Center for Substance
Abuse Treatment
• Planning committee of diverse people in
recovery and their supporters
• Energizing and source of new connections
• Significant risks were taken to reach across
the divides of recovery pathways
Mental Health and Addiction
Benefit “Parity”
• In the U.S., most health care is paid through
private insurance
• 2008 law outlaws discriminatory coverage
of mental health and addictive disorders
• Recovering people inside and outside of
government critical to law’s passage
Recovery as Central to Policy
• Office on Recovery Created in White House
• Unprecedented outreach to recovering
community
• Initiatives to change laws that punish people
in recovery
• 2010 Summit at the White House
• Think-tank co-hosted with FAVOR
Affordable Care Act
• Largest expansion of health insurance in US
in over 40 years
• Full coverage of all stages of substance use
disorder treatments
• Potential to cover recovery support services
• Regulatory rules extend or improve
substance use treatment coverage for over
60 million people
Stirrings in Scotland
William (Bill) White at the Scotland Futures Forum
Scottish Policy Initiatives
• SACDM Methadone Project Group (2007)
• Scottish Government Road to Recovery
(2008)
• Research For Recovery: A Review of the
Drugs Evidence Base (2010)
SMART expansion project
• Partnership between DoH, Alcohol Concern
and SMART Recovery UK
• Developed training, local champions,
referral processes in 6 sites in England
• Established 18 groups in 4 regions (12
original, 6 spinoffs)
• Raised profile of SMART with
professionals and public
Source: Macgregor, S., & Herring, R. (2010). The Alcohol Concern SMART Recovery pilot project final evaluation report. Middlesex University.
Other Recent UK Developments
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•
•
•
•
•
•
•
UKDPC Statement on Recovery
Recovery Partnership
ACMD Committee on Recovery
Recovery Festival
Emergence of RCOs (e.g., Living Room)
Methadone-Recovery Work Group
Annual Recovery Marches
Emergence of Recovery Coaching
Highlights of Scientific Evidence
on Effectiveness and CostEffectiveness
Clinical trial of Oxford House
• Oxford House is a democratic, selfsupporting, peer-managed residential setting
• 150 Patients randomized after inpatient
treatment to Oxford House or TAU
• 77% African American; 62% Female
• Follow-ups every 6 months for 2 years,
90% of subjects re-contacted
At 24-months, Oxford House (OH)
produced 1.5 to 2 times better outcomes
80
70
60
50
OH
TAU
40
30
20
10
0
Abstinent
Employed
Incarc
Jason et al. (2006). Communal housing settings enhance substance abuse recovery. American J Public Health, 96, 1727-1729.
Veterans Affairs RCT on AA/NA
referral for outpatients
• 345 VA outpatients randomized to standard
or intensive 12-step group referral
• 81.4% FU at 6 months
• Higher rates of 12-step involvement in
intensive condition
• Over 60% greater improvement in ASI
alcohol and drug composite scores in
intensive referral condition
Source: Timko, C. (2006). Intensive referral to 12-step self-help groups and 6-month substance use disorder
outcomes. Addiction, 101, 678-688.
Incorporating mutual-help principles in
treatment increases cost-effectiveness
Sample:
249 low-income alcohol-dependent patients
Design:
Random assignment to usual care or experimental
unit with 50% less staff and higher expectation of
patient self and mutual help
Results:
One-year outcomes comparable except for better
social adjustment among experimental patients
Source: Galanter, M. et al. (1987). Institutional self-help therapy for alcoholism: Clinical outcome. Alcoholism: Clinical &
Experimental Resesarch, 11, 424-429.
Cost offset findings in an NHSlike Health Care System
Source: Humphreys, K., & Moos, R. H. (2001). Alcoholism: Clinical and
Experimental Research, 25, 711-716 and (2007). Alcoholism: Clinical &
Experimental Research, 31, 64-68.
Design
• Follow-up study of over 1700 VA patients
(100% male, 46% African-American)
receiving one of two types of care:
• 5 programs were based on 12-step
principles and placed heavy emphasis on
self-help activities
• 5 programs were based on cognitivebehavioral principles and placed little
emphasis on self-help activities
1-Year Clinical Outcomes (%)
50
45
40
35
30
25
20
15
10
5
0
12-step
Cog-Beh
Abstinent
No use-related problems
Note: Abstinence higher in 12-step, p< .001
Treatment programs that strongly promote recovery
mutual help involvement have lower 1-Year Costs:
Study of over 1,700 substance-dependent veterans.
Humphreys, K., & Moos, R. H. (2001). Can encouraging substance abuse inpatients to participate in self-help
groups reduce demand for health care?: A quasi-experimental study. Alcoholism: Clinical and Experimental
Research, 25, 711-716.
2-year follow-up of same sample
• 50% to 100% higher self-help group
involvement measures favoring 12-step
• Abstinence difference increased: 49.5% in
12-step versus 37.0% in CB
• A further $2,440 health care cost reduction
(2-year total in current value $9400/£6000)
Humphreys, K., & Moos, R. (2007). Two year clinical and cost offset outcomes of facilitating 12-step self-help group participation.
Alcoholism: Clinical & Experimental Research, 31, 64-68.
Transatlantic Observations
US-UK Parallel
• No Political Party “Owns” Recovery
• The Recovery Movement works with those
policymakers who will help people in
recovery and their family (irrespective of
party)
Two Nations Separated by
Different Cultural Myths
• “Any child can grow up to be President of the
United States!”
• “Let me hear your accent, and I will tell you
what your father did for a living.”
Expectations of the State and
Professional Helpers
• “Leave it to the professionals”
• “If you want something done right…”