THE NEW SCIENCE ON MUTUAL HELP –
AND COST CONTROL
Rigorous studies by the scientific community on the clinical and cost benefits of mutual-help groups – plus testing professional paths to encourage their use – mark 12-step groups moving from the periphery to a central role in scientifically-informed recovery. John F Kelly and Julie Yeterian reveal the research.
Print-friendly version, from May 2012 Addiction Today journal:
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Over the past 75 years, Alcoholics Anonymous has grown from two members to over 2million members. AA and similar organisations such as Narcotics Anonymous are among the most commonly-sought sources of help for substance-related problems. But it is only relatively recently that the scientific community has conducted rigorous studies on the clinical utility and healthcare cost-offset potential of mutual-help groups and developed and tested professional treatments to facilitate their use.
As a result of this research, AA has experienced an “empirical awakening,” evolving from its peripheral status as a “nuisance variable” to playing a more central role in a scientifically informed recovery-oriented system of care.
Also, professionally delivered interventions designed to facilitate the use of AA and NA – Twelve-Step Facilitation – are now “empirically supported treatments” as defined by US federal agencies and the American Psychological Association. The World Health Organisation and, in the UK, Nice recommend their use.
This article describes six lessons learned in the past 15-20 years regarding the impact of substance-related problems, how mutual-help organisations can help, and the potential implications for reducing healthcare costs.
SIX LESSONS FROM THE PAST 15-20 YEARS
1. Substance use and related disorders confer a massive health, social and economic burden.
2. Mutual-help organisations help offset this burden and can be studied empirically.
3. Mutual-help groups confer clinically- meaningful benefits for many different types of individuals over and above formal treatment.
4. Mutual-help groups work through mechanisms similar to those operating in formal treatment.
5. Mutual-help group participation can reduce healthcare costs by reducing patients’ reliance on professional services without any detriment to outcomes, and might enhance outcomes.
6. Empirically-supported clinical interventions increase patients’ participation in mutual-help groups and enhance treatment outcomes.
SUBSTANCE USE & RELATED DISORDERS CONFER A MASSIVE HEALTH, SOCIAL AND ECONOMIC BURDEN
Globally, the misuse of alcohol and other drugs results in an extraordinary social and medical burden. Alcohol alone is the leading risk factor for death among males aged 15-59 and alcohol-use disorders account for a disproportionately high 36% of all the disability-adjusted life years lost due to about 400 established psychiatric disorders. In the US, alcohol use is the third leading cause of death and the financial impact of SUD is estimated to approach $400billion annually, stemming mostly from lost productivity and criminal justice and healthcare costs.
In most developed nations, the societal response to these endemic public health problems has been multipronged, including prohibiting certain substances; attempts to reduce consumption through price controls, taxation and licensing of sales outlets (in the case of alcohol); federal, state, and community prevention initiatives; and the provision of various forms of professional treatment. In addition to these considerable formal efforts, peer-led mutual help organisations have flourished in most communities in the past 75 years, perhaps stemming from recognition at the grassroots level of the need for more flexible, rapidly accessible, and ongoing support that can mitigate relapserisk at little to no cost.
MUTUAL-HELP ORGANISATIONS HELP OFFSET THIS BURDEN AND CAN BE STUDIED EMPIRICALLY
By far the largest and most researched of these peer-led mutual-help organisations is AA. Increasingly sophisticated scientific evidence has supported the role of AA and similar groups in helping individuals achieve abstinence and maintain recovery. This line of research has culminated in a strong evidence base in support of professionally delivered interventions (ie, TSF) designed to effectively engage individuals with these community resources. This extensive empirical work has taken community organisations such as AA and NA from their peripheral status to a more central, science-based place in a recovery oriented system of care.
AA purports that the primary mechanism through which recovery from alcoholism is achieved is through a “spiritual awakening” which is realised by following a sequential 12-step programme. Such spiritual processes might seem antithetical to empirical study. But research over the past 20 years has shown that there are many aspects of AA and its mechanisms of action that are amenable to empirical study, including spirituality and spiritual practices.
Studying AA empirically is not without its challenges, particularly in terms of the gold standard of treatment research: the randomised controlled trial. The tightly controlled and highly insulated context of an RCT runs counter to the way real-world AA groups are conducted. AA is attended anonymously, usually voluntarily. No records are kept about who attends and what is said. Groups vary widely in their size and content. Because AA is freely accessible in the community, it can be seen as unethical to randomly assign some RCT participants to attend and prohibit the attendance of others.
These issues have led researchers to examine AA through other methods, such as through naturalistic, prospective effectiveness studies.
Researchers have also examined the efficacy of professionally delivered TSF treatments, which systematically encourage and facilitate 12-step meeting attendance, relative to other treatments that neither encourage nor forbid attendance.
In combination, these types of research provided insight into the benefits of AA attendance in a way that has both scientific integrity and real-world relevance.
MEANINGFUL BENEFITS FOR MANY DIFFERENT TYPES OF PEOPLE OVER AND ABOVE FORMAL TREATMENT
There have been hundreds of empirical studies on AA, summarised in several meta-analyses and one Cochrane review. These reviews found that AA is associated with a moderate effect on alcohol and other drug use that is on par with professional treatment. For some people, mutual-help group participation alone can serve as an effective intervention for substance-use disorder.
Questions can arise as to whether AA is less suitable for certain groups of people, particularly dually diagnosed people, those taking psychotropic or antirelapse medications, atheists or agnostics, women and youth. These are perceived to face additional barriers to attending 12-step groups purely focused on addiction recovery, considered by some to have an overly rigid emphasis on abstinence from any substance including potentially beneficial medications, are spiritually oriented, emphasise “powerlessness” (over alcohol) that some women might find objectionable, and are made up largely of middle-aged adults. But the available empirical evidence suggests that, for the most part, such people benefit from participation in regular AA meetings.
One exception might be people with severe impairments in psychosocial functioning and reality testing – such as co-occurring schizophrenia and SUD – who might benefit more from dual-diagnosis mutual-help groups such as Double Trouble in Recovery.
Similarly, although young people can benefit from attendance at AA and NA meetings, benefits can be enhanced by attending meetings with at least some same-aged peers.
MUTUAL-HELP GROUPS WORK THROUGH MECHANISMS SIMILAR TO THOSE IN FORMAL TREATMENT
Over 20 years ago, the Institute of Medicine called for more research on how AA works. A recent review of the research on the mechanisms of change in AA has revealed that AA helps people to attain and maintain recovery through multiple mechanisms, many of which are also activated by formal treatment. Most consistently and strongly, AA appears to work through mobilising adaptive changes in the social networks of attendees – for instance, decreasing pro-drinking social ties and increasing proabstinence social ties – and enhancing coping skills and self efficacy for abstinence in high-risk social situations.
Among more severely alcohol-impaired people, AA also appears to work by enhancing spiritual/religious practices, reducing depression and increasing individuals’ confidence in their ability to cope with negative affect. Thus, AA appears to work through diverse mechanisms and might work differently for different people.
MUTUAL-HELP GROUP PARTICIPATION CAN REDUCE HEALTHCARE COSTS AND COULD ENHANCE OUTCOMES
Substance dependence is recognised as a chronic, relapsing condition which typically requires multiple episodes of care over long periods of time. Unfortunately, individuals’ access to professional healthcare resources is often limited to short periods of time by insurance coverage or insufficient personal funds. In the US and UK, government policies have an ever-increasing impetus to reduce healthcare costs and create a more cost-effective system.
Mutual-help groups are a crucial adjunct to professional treatment, as they can be attended for as long as necessary at no cost except for voluntary contributions. Not only are 12-step organisations self-supporting and inexpensive to attend, but research has shown that involvement in 12-step organisations can reduce the need for more costly professional treatments while simultaneously improving outcomes.
One study found that people who attended only AA had overall treatment costs substantially lower than people in outpatient treatment, at no detriment to their substance use outcomes and despite experiencing more drinking-related consequences at the start of the study.
Similarly, a large prospective study of over 1,700 substance-dependent males found that those in professional 12-step treatment participated in community-based AA and NA meetings much more following treatment than those from professional cognitive behavioural therapy treatment programmes, who relied more heavily on professional services. This translated into a two-year savings of over $7,000 per patient, again without compromising abstinence rates.
In fact, patients treated in the 12-step programmes had one-third higher rates of abstinence than those treated in the CBT programmes at two-year follow-up (demographic and clinical severity indicators were largely equivalent between groups at baseline).
CLINICAL INTERVENTIONS CAN GROW PARTICIPATION IN MUTUAL-HELP GROUPS AND ENHANCE OUTCOMES
Since AA and related organisations appear to be effective and cost-effective public health resources, the question arises as to how clinicians can best facilitate their patients’ engagement in these groups. Many SUD counsellors report that they refer their patients to 12-step meetings, but the degree to which clinicians provide facilitation efforts beyond a simple referral is unclear. A growing body of research on TSF interventions suggests that taking a more intensive and proactive approach to facilitating attendance can be beneficial for patients.
The overall aims of TSF approaches are to educate patients about how 12-step organisations can support their recovery and to facilitate patients’ active involvement in these groups. Clinicians monitor and discuss patients’ reactions to meetings and explore reasons for nonattendance.
TSF can be delivered in several formats, including as a standalone treatment, brief intervention or as part of another treatment.
Studies have demonstrated that clinicians using these more intensive facilitation efforts can substantially increase the likelihood that patients will become and stay involved in these organisations. One early study found that, when therapists actively linked patients with current 12-step group members by having them speak over the phone during a session and make arrangements to attend a meeting, every patient attended at least one meeting during the month following referral. In contrast, when patients were simply given information and encouraged to attend, not one person attended.
In Project Match, participants in the TSF condition attended AA at a significantly higher rate than those in the CBT and motivational enhancement therapy conditions in treatment and during the first three months of follow-up.
Another RCT compared standard 12-step referral, in which patients were given a schedule of meetings and encouraged to attend, to intensive referral, which included directly linking the patient with a current AA/NA member and addressing patient concerns about attendance. At six-month follow-up, those in the intensive referral condition became more involved in several aspects of the 12-step programme. For example, they were more likely to have a sponsor.
Importantly, studies have shown that TSF has a positive impact on patients’ substance use outcomes. In Project Match, for example, TSF was as effective as the more empirically supported CBT and MET at reducing alcohol use post-treatment, and at one- and three-year follow-ups. Moreover, TSF was superior to CBT and MET at increasing rates of continuous abstinence.
Similar findings have been demonstrated in several other RCTs using various forms of TSF. These studies consistently show that TSF interventions produce outcomes superior to control conditions. As a result of this growing empirical support, TSF was recently recognised as a “well supported treatment” by the Division of Clinical Psychology of the American Psychological Association and added to Samhsa’s National Registry of Evidence-Based Practices and Programmes in 2008.
SUMMARY AND CONCLUSIONS
The often-passionate debate about the pros and cons of mutual-help organisations seldom references the accumulating body of scientific literature amassed during the past 25 years. This “empirical awakening” and related science base supports the effectiveness of 12-step mutual-help organisations and the efficacy of TSF interventions for reducing substance-related problems.
Other non-12-step mutual-help groups such as Smart might provide similar benefits, but await more extensive empirical study.
The chief strength of community mutual-help organisations might lie in their ability to provide effective, easily accessible, free, long-term recovery support which is responsive to undulating relapse risk.
As we move to constrain healthcare costs, awareness of the important role mutual-help organisations and related professional interventions can play in a recovery-oriented system of care will enhance the proficiency of our overall response to the burden imposed by substance-related harms.
The 52 research references will be uploaded to this site after John Kelly has given his presentation at UKESAD,10-12 May 2012.
MEET JOHN F KELLY AT UKESAD... He is associate professor in psychiatry at Harvard Medical School, associate director of Massachusetts General Hospital-Harvard Center for Addiction Medicine and programme director of Addiction Recovery Management Service. A leader in programme evaluation and addiction treatment and recovery research, he is a consultant to the White House Office of National Drug Control Policy, the Substance Abuse and Mental Health Services Administration, the Center for Substance Abuse Treatment and the US Department of Education. He also serves on the executive committee of the American Psychological Association, Division on Addictions, and as a scientific consultant to the National Institutes of Health. He has published over 70 scientific articles, reviews and book chapters on addiction.
JULIE D YETERIAN is affiliated with the Massachusetts General Hospital, Boston.