Okay, good afternoon or good evening, everyone. It looks like a lot of you have joined and people are starting to trickle in. So welcome back to our AAAP psychotherapy curriculum. We meet every month on Wednesdays at 2.30 Pacific time. This is our first talk of 2023 and we'll be meeting monthly all the way through May. So thanks for joining us. Just to remind you, this program is curated for professionals in addiction psychiatry. Participants will be able to explore advanced techniques in patient management from talks with clinical experts and the skills and principles can be readily applied to real world clinical settings. These live webinars, which have been developed by the American Academy of Addiction Psychiatry in collaboration with Oregon Health and Sciences University and the New York University School of Medicine are a great way to interact with top faculty in addiction psychiatry and keep up to date with the best practices in patient management. Just to reintroduce myself, I'm one of the course directors, Dr. David Stifler. I'm at NYU and my colleague and co-director is Dr. Chris Blazes, who is at OHSU. Just to highlight some of the upcoming talks today, I'll let Dr. Blazes introduce our speaker and then in February, we will be, or in the upcoming months, we will have an update on smart recovery and then also two talks on psychodynamic and psychoanalytic psychotherapy. So I'll turn it over to you, Dr. Blazes. All right, once again, I'm Chris Blazes from OHSU. This evening's session is 12-step facilitation and self-help groups for addiction. And we're very fortunate to have Dr. Keith Humphreys speaking today. So he's the Esther Ting Memorial Professor in the Department of Psychiatry and Behavioral Sciences at Stanford University. He's also a senior research, has a senior research career scientist at the VA Health Services Research Center in Palo Alto and an honorary professor of psychiatry at the Institute of Psychiatry at King's College in London. His research addresses the prevention and treatment of addictive disorders, the formation of public policy and the extent to which subjects in medical research differ from patients seen in everyday clinical practice. And I think that's another way of saying translational research. And I think that that's really the most, the area of his research that I'm most interested in. That's a very humble introduction. He's written multiple books. He's published hundreds of articles in all of the highest impact journals. I think the last time I checked, there was 20,000 citations. He's on the editorial board of multiple journals with very high impact. And so we're really grateful to have truly one of the kind of pioneers in our field and the most influential researchers and teachers in the field. So thank you, Dr. Humphreys for being with us. Thank you. Sorry, Dr. Humphreys, one more housekeeping item that I missed. Just to remind everyone, you will be able to ask questions. You can just click the question icon in the lower part of your screen and type in your question. Dr. Blazes and I will field those and likely save them for the end. We should have around 15 minutes. We'll be able to address your questions and ask them for you or maybe prompt you to ask them for discussion. Okay. So thank you. Thank you, Dr. Stifler and Blazes and thanks to the team for setting this up. I'm really excited to speak to this group. Can you just give me a nod, David? Can you hear me okay? Okay, great. So I'm gonna talk to you about something that when I started my career, I never thought I would find interesting or compelling, which is self-help groups for addiction. I got into the addiction field very accidentally. I literally did it because I was flipping burgers as a college student and there was a job open that paid more than flipping burgers with another dollar an hour. And it happened to be an addiction, but I would have done anything to get out of flipping burgers. And so I didn't know anything about addiction beyond like all of us, I had known people who had had problems with substances. And there were people on the project who used funny phrases like, fake it until you make it and put some gratitude in your attitude. And I asked them what this was. And they told me they were in 12-step groups like AA and NA. And I said, what is that? And they said, well, it's a way we try to recover from addiction. We share our experience, strength and hope. And I thought at the time, I'm not proud of it, but probably snobbishly that can't possibly work because you've got no doctors there, no nurses, no psychiatrists, no social workers, you don't have any medication, you don't have any training. How could that possibly make a difference in dealing with such a serious disorder as addiction? And over the years after that, my mind was changed by evidence, sometimes by studies I did, but just as much by studies other people did. And many other people have had this experience of initial skepticism or maybe some snobbishness because it's not professionally designed and delivered. And which is the good thing about research is sometimes it proves that we were wrong about something. So if you're in that place where you don't have much confidence in them, I say I've been in that position too. I'm hopeful though that as I walk through the evidence, it will give you another way to think about these organizations. Okay, so this is a talk about self-help groups. We're not gonna discuss pharmaceuticals, medical devices or anything for profit, and I don't have any conflict of interest here. So one of the first things you notice when you look around the world is how common addiction self-help or sometimes called mutual help organizations are. And certainly there's a 12-step group, which everyone knows, but there's plenty of others. Austria has the Blue Cross, which was started out of the Catholic church. France has a workers-based recovery movement for alcohol that came out of the union movement. Hong Kong has a very big alumni association of people who've been through formal treatment and keep in touch and sort of support each other mostly in dealing with heroin use disorder. Japan has Danshukai, which is influenced by AA, but it is very much its own thing. And not least the fact that people attend as couples rather than as individuals. Poland has abstainers clubs, which are non-anonymous. They even have a TV show where people talk about being in abstainers clubs. But, and so that's quite different, obviously, than AA. Sweden has The Links, also influenced by AA, but again, its own character. And I put Iran here because it surprises a lot of people. Iran has its own variant of Narcotics Anonymous, which was something, earlier in my career, people say it would never happen that 12-step groups would spread to the Muslim world, but they have, and probably about one in five or one in four NA members in the world are actually Iranian. And they've heard they meet out in the parks under the sky. It sounds really wonderful. But so what does that tell us? It seems to say across cultures, very different cultures, and very different kinds of addictions, people do seem to find some connection with other people with the same problem. And maybe because that's deeply stigmatized, so it's less shameful, or maybe it's because there's just the shared, like many other activities, if you're in a running group, it's easier to keep running. If you're in a weight loss group, it's easier to keep your weight off. That's a sort of common behavioral support that we're all very familiar with. But whatever it is, this seems to be something people often do and often seem to benefit from with addiction. And the Tuasa groups are example of that, but clearly not the own example of that. If you're interested, I did write a book, which you can get, I think, probably quite cheap, that bounced around on the internet called Circles of Recovery, that looked around the world at all these different groups. You can learn about that if you'd like to. So AA is the prototypical, and in the United States, it's the biggest, it's influenced many others. I'm just gonna go through this history briefly. I suspect many of you know it better than I do, but it was started in Ohio, Akron, Ohio. In fact, I had a nice opportunity to look at the home of one of the founders when I was giving a talk at the University of Akron not long ago, just by two people. And Bill and Bob were their names. They said their sole purpose was to help alcoholics become sober. And I put alcoholics in quotes because that's not a word we use clinically, but it is what people in AA refer to themselves as. And since I think people should be allowed to call themselves what they want, we use it when describing their experience. In becoming sober, they had a particular idea that this was not just abstinence. They certainly say you should never drink again, but they also meant sober, meaning to achieve serenity, to achieve a particular psychological, spiritual outlook on life based on service, oriented away from selfishness, towards being responsible, towards having good relationships. And it was all those things together, plus abstinence, that they thought of as the goal of AA. AA has meetings, as we all know. It has sponsors where a more experienced member will help a less experienced member who goes through the process. There's lots of literature, and it has the 12 steps as things people can walk through. Surprisingly to many people, the 12 step literature actually says the 12 steps are but suggestions. You're not mandated to do them, but most people end up doing them or at least doing some of them. It's got a disease model. Again, I'm using quotes here because they didn't mean that in a biological way strictly. They saw it much more, they wouldn't have said biopsychosocial or spiritual, but if that term had been invoked, they might've used it. But they wanted to describe alcoholism as something that is in the person and is a basic uncomfortableness with life, oriented around self-will. And that was the core problem. It even says in the book how it works. Selfishness, that we think is the core of our problem. But so it was really, it's more than just the drinking in their understanding. They used the word disease, but they didn't mean it biologically, but much more in sort of spiritual psychological way. It's one of the most successful organizations of any sort in the world. I mean, it starts in 1935 with two people. By 1950, it has 50,000 people. And today it probably has something like five or 6 million people in it all around the world. And there is AA in at least 190 countries, perhaps even more. It's a huge influence on our field for sure. And a huge influence on the public understanding of addiction. And it's the most widely sought source of help for alcohol in the United States. If when someone is, an American is leaving their house, seeking help for an alcohol problem, the odds are very, actually far less likely they're seeing someone like me or you, that they are going to a meeting. That is where the most visits are made. The number of visits to meeting far exceed the number of visits to psychiatrists, psychologists, social workers, nurses, all put together. So it's super popular, but that doesn't mean it works. Something can, there are many, many things in health that people love to do, but they don't actually have any effects. So my grandmother took like many people in her generation, Carter's little liver pills. Millions of people took Carter's little liver pills until the FDA pointed out that those pills were inert. They couldn't possibly affect your liver. So they kept selling them. They just called them Carter's little pills and people still took them. And again, they did nothing, but they were very popular. So the fact that lots and lots of people go to AA and that it's spread all over the world does not mean in itself that people get better. And a lot of the early studies, which some people took to show that it worked, for example, showing up at a meeting and, you know, with permission and surveying people and showing the people have been here longer and doing better than people have been there, not as long are pretty weak, you know, correlational single group studies. And so there wasn't really rigorous research in this area until maybe 20, 25 years ago, where we started to get trials that we could believe. And this is one of the most important ones. It was done by my colleague and my friend, Chris Timko. So it was actually done at our VA in Palo Alto Mental Park. And the thing is, you know, that Chris figured out is, since you can't really control AA and randomize it, like you could a pill or a surgical procedure, how do you get some kind of, you know, randomization-like estimate of whether or not it works? And so what she did was she invented a warm handoff into AA. So with people who were already in treatment for substance use disorder, but half of them got probably the usual standard of care in the US, which is, you know, here's a brochure, there's these groups, you can go if you want to. But the other half got a, like a half-hour introduction. Here's what the groups are. Here's what might happen in groups. Here are groups in this area. Do you have any concerns about the groups and any anxieties you want to share, any questions you have? And I would like to connect you to somebody who will take you to your first meeting experience member. So it's a warm handoff. And so what she showed with a very high follow-up rate is first off, just that warm handoff, even though it's not very long, significantly increased people's likelihood of attending 12-step groups after they got out of treatment. And they also, she also found that there was a much greater improvement in outcomes. This was measured with the addiction severity index, about 60% greater improvement. And addiction severity index, it's backwards. Your score goes down, meaning you're getting better. And in the people who got that warm handoff into self-help, it produced a remarkably large effect. And again, this isn't a randomized study. This is not the self-selection thing of let's see who goes, but this actually was people who were prompted to go by a referral that was assigned randomly. That's pretty impressive. This study is very, very important. I mean, I've since had others like this, but this was a real breakthrough. And it's certainly not just one site or one researcher or one population. You can also see this in really different work. Mark Lit and his colleagues out in Connecticut did a randomized trial of something called network support therapy, where you link people to as many abstinent social networks as you can. And those could be many things. You know, that could be sports teams or maybe the religious organization the person belongs to or other activities that are inconventional with drinking, but also to AA. And what they showed in comparing people who were randomized, these were people with, you know, I'd say not quite as severe substance use disorders as Chris studied in the VA, but still definitely meeting diagnostic criteria, to case management or to network support, that the network support approaches produced higher AA involvement and more abstention days. And again, this is a randomized clinical trial, not a self-selected sample. As more of these studies have been supported either in the VA or by NIAAA, it became possible to put them all together. And I did this work with Janet Blodgett and Todd Wagner. We used a procedure from economics called instrumental variables analysis, which lets you estimate the exogenous effect of something. In other words, the part that is truly free of self-selection bias. And so we took all those studies that had done. There've been six trials, including Project MATCH, which together had over 2000 patients with alcohol use disorders and used instrumental variables to estimate, does AA truly have an effect that is in no way explained by selection? In other words, that people are more motivated or that they may have easier problems to solve or whatever. And it came out in five of the six trials that yes, AA's effect was there, significant and positive. Interestingly, the one trial arm where it didn't have an effect was the Project MATCH inpatient arm. And I think that's probably because people in that particular study had been through many, many, many meetings of AA and then went through an inpatient program that gave them many, many more meetings of AA and then encouraged to go to AA afterwards. So in that sense, you probably have a selection effect of the form that if AA was going to help that particular group, it would have done so already. And these are the people who had continued drinking through all of that. So that study did not show an effect, but all the others did. We replicated that or tried to replicate that with studies that had been done of illicit drug focus groups like cocaine anonymous and narcotics anonymous. And all the people listed in the title slide here very kindly donated data from trials they had run. First, Sheila Alessi was the first one, and then Kathy, Paul, Dennis, John, and Rich all gave us their data. And Chris and Todd and I worked together on this with Nick Barretto doing the stats for us. And these were mostly out of the CTN, NIDA CTN. And again, we asked the same question. In these studies where you actually have a randomized assignment to go to these groups, do in fact people get better? Well, the data here candidly was not as strong as what came out in the AA trials. So first off, we found out, actually before I do this, I'll just tell you this part. We found out that the warm handoffs don't work as well for the illicit drug groups. So we couldn't use intramural variables models because to do that, you need to have a really strong case that something was not self-selected and it was harder to get because the people who got the encouraging 12-step facilitation counseling were only modestly more likely to end up going to NACA and so on. So we couldn't run a strong study that way. We did find though, that at least using more traditional regression analyses, controlling for bias as well as we could, that all the facts were friendly. I mean, the people who went had a lower ASI drug composite, lower alcohol composite if they had a comorbid alcohol problem. These kinds of models, as you know, are more subject to selection bias. So I can't be as confident about this, the effect of these groups as I can about AA. Also worth noting, good news, is that there was no difference in who went by race or by gender, which is sort of remarkable because these groups were created by white males entirely, but there is no sign that that's all they appeal to. They seem to appeal across the demographic spectrum equally. So that's certainly good. So how strong is this kind of evidence? I would say in the drug field, it's not as strong as I would say for medications or for contingency management where we have lots of good clinical trials, but it's pretty good, pretty good evidence that these are beneficial. And there's no reason, of course, you can't do more than one thing when you're working with people. So you could do contingency management and per se someone with a stimulant addiction and also refer them to NA or CA as you see fit. With the medications and combined with groups, there can be some issues there and I'll try to get into that a bit later. As this area was maturing and it seemed to me there was something there, including the great work that Chris had done, I started to get interested in the cost implications of this and did some work with my original mentor, the person who hired me, brought me to Palo Alto, Rudy Moose. And we thought, well, these groups don't cost any money. That's an interesting thing about them. Do they perhaps take economic burden off the healthcare system? And so we decided to look at that and we looked in the VA to see. So the kind of design we had was 10 inpatient programs, 21 to 28 day VA programs that were either very strongly based in 12 step principles. And we tested this book by sending an anthropologist to each of the programs and looking at all their program materials and knowing how many of the staff were in recovery or promoted recovery and so on. And the other five were very good places that did cognitive behavioral kinds of treatment, the kind of treatment I was trained to do. It works very well, but they really didn't put any emphasis on mutual help involvement or any kind of 12 step activities. That's how they were different. And people got one of these two types of care. We had about 1,700 patients in here. The generalizability limit is these are all male. So that is a limit, good racial diversity to the sample. And we wanted to see what are the consequences if you go to a VA program that is very 12 stepy, that is a word versus very much not that way. We matched the samples on their prior mental health and substance use care utilization. And then we looked to see, were they different? Because this is a quasi experiment. The programs are hundreds of miles apart. So pretty much you get what you get, but they weren't randomly assigned. So we looked, are they different on any prognostic measure? And no, they weren't different on any prognostic measure. So we thought we could draw a causal inference and we had very high follow-up rate. So first what we showed is, again, like Chris's study, if you really emphasize during treatment, the importance of going to a self-help program, people are more likely to go. And a year later, they were more likely to have a sponsor. They're more likely to attend groups. When they attend them, they attend them more often. So that part worked, but did it help them? Well, it seems to have been a good outcome. So we had three core outcomes. The first one was abstinence, and it was a very rigorous abstinence measure is any use of anything in the year after treatment. And the people who'd gone to the 12-step treatment group actually did significantly better on that measure. The other two measures were consequences of substance use and mental health, positive mental health. Those were both the same. So people were significantly better off in both conditions, but a bit better off in the 12-step condition, at least on the outcome of abstinence. So now we go to the question of cost. And this is pretty interesting, I think. So the cognitive behavioral treatment is the kind of teal colored bar, and the 12-step is the orangish colored bar. And these are how much money was spent on their mental health and substance use care in the year after they left the inpatient program. And you can see there's quite a difference there, about a 40% difference in cost. People who went to the 12-step condition were less likely to go back for more inpatient care for mental health and substance use, and less likely to make a further outpatient visits. So what's unusual about this, you have to think about these two slides together. Outcomes as good or better and less healthcare. Normally, when people get less healthcare, they're sicker because maybe the budget didn't go as far as they needed it to go. But here you have a case where less money was spent in services and the group is doing well or better. How do you explain that? We didn't have a direct test of that in the study. So I don't know, but I will tell you my speculation, and it's this. If you go into pretty much any primary care clinic in this country, you will see people in the waiting room who are sick, for sure. You also see people who are lonely, who are bored, who just need a pat on the back, who just need to talk to somebody, have the world know they exist. And those are all very important needs. I have them, you have them, but you don't need an MD or a PhD or an MSW to fulfill those needs. So one possible theory of what's going on is people are learning to go to their groups for those kinds of needs, those basic human needs that you don't need a medical degree to fulfill. And just reserving, they only go to the doctor when they need to see a doctor. And that's how you can have this sort of mystery of less care, but better health. And this is, of course, good because ideally we would, it's hard to say, finding a good psychiatrist is hard. It would be great if the only people go to see a psychiatrist so that people really need to see a psychiatrist. So that's good in terms of efficiency of care. And then it helps us with this problem that we always have. We're always asked to do more with less. Well, here's a case where you actually can make care more efficient without harming your patients by connecting them better with well-staffed programs. Now, that was a one-year data. So we then followed it up at two years and again found that the effects were there. In fact, they were even stronger. So the difference in how much self-help groups people were going to was getting even bigger for the groups who had been through, people had been through the self-help oriented treatment and the absence difference increased as well. So people are now doing substantially better. That's about a third better in terms of being completely abstinent than those who've been to the 12-step condition. And there was a further healthcare cost reduction. So again, you saw the pattern in the second year of not as much outpatient care, not as much inpatient care, but it's again, better health, higher rates of abstinence. So together that was about $10,600. That was the 2014 dollars. You would inflate that to current money. Maybe that's probably what, 14,000 or something in today's dollars per patient. And the VA treats over 100,000 substance use disorder patients a year. So you multiple those things together and realize that's a lot of money that these groups are saving the healthcare system and promoting health at the same time. So this is really like the ultimate, John Kelly, who I work with on some of these projects, says it's really the complete free lunch. We don't pay any tax dollars into it. It doesn't cost any staff time and it reduces the cost of the healthcare system while promoting recovery. That's kind of remarkable. We're lucky that it exists. All of us who work in healthcare are lucky. So John Kelly, who I just mentioned, and I, along with Marika Ferry, recently decided to try to pull every good study together in the most rigorous way possible. And we did that with a Cochran Review. So everything that is studies of AA, as well as 12-step facilitation, which, as you probably know, is where you're introducing a lot of 12-step ideas in treatment. And there's a nice manual from NIAAA that gives the instructions on how to do this session by session. It can be done. It was originally conceived as a 12-week, I think, but it can be done in shorter or longer formats. But basically, it's sort of a graded introduction to the program in this message. And so we pulled all that together in a Cochran Review. So if you don't know what these are, they are super, super rigorous reviews. You have to submit, even before you start your literature review, you have to submit how you're going to review the literature, which goes through very rigorous review and up for public comment. It took a year just to get that agreement. And then a super rigorous coding process. And John Kelly deserves huge credit for this because he and his team did the lion's share of this work. And I think we had eight different editors who oversaw the process. So this is as rigorous as you get in time to pull together all the evidence in any particular area. So we were able at this point, as I mentioned early on, AA research was not very strong. A lot of single group studies, a lot of just simple correlational designs. We can be much more choosy than that. We included mostly randomized trials or quasi-randomized trials. And only studies that compared AA or 12-step facilitation to good treatments like motivation enhancement therapy, cognitive behavioral therapy, treatments that we know work. We also included economic studies, sort of like the one I just showed you, but other people have done those. And we took only adults, non-coerced adults. So this is not necessarily applied to adolescents about whom we don't have as much data yet. I'm going to go through all the details of this. It's online, it's free, and in the public domain, you can read it. But just to say, we really, really, you know, scoured the literature internationally to try to find every single appropriate study that could be included. And it turned out there were a lot. There were 27 primary studies with over 10,000 people in mostly randomized clinical trials. These studies were done by different investigators. They were, many were in the United States, but many were not in the United States. So normal source of bias you might have, you know, maybe one investigator with a particular strategy or a particular viewpoint or a particular country with a particular set of ways of looking at, you know, research or addiction for that matter. That isn't really possible when you have this many sources contributing data. So it's a really good chance to draw a strong conclusion. We looked at different outcomes. These were all pre-specified. Abstinence, of course, but not just complete abstinence, but, you know, percent days abstinence, longest periods abstinence. We also looked at more measures of non-abstinence like drinking intensity. So maybe the person's still drinking, but are they drinking fewer drinks per drinking day or having fewer days of heavy drinking out of all their drinking days? We looked at alcohol-related consequences, alcohol addiction severity, and we looked, as I mentioned, with economic analyses of impact on healthcare prices. And this was probably the most stunning finding. This is continuous abstinence. So we looked at many outcomes, but continuous abstinence, in a sense, you know, that's like the perfect state, right? You know, it's, you know, if you have cancer, you want to be completely clear of cancer. If you have, if you're addicted to alcohol, be continuous abstinence is like that in terms of totally removing a very serious illness from your life. And these trials, the blue bars are the 12-step psilocybin AA conditions, and the comparison treatments are the orange and grayish bars. You can see that the blue bars are a lot taller. If you, you know, like I said, if this were cancer care, you would want to start with the blue bar if you were a patient, sometimes twice as much, sometimes more than twice as much chance of continuous abstinence. This is really a whopping effect. Now, AA emphasizes abstinence, so you might think, oh, but that's gotta be the only benefit. Probably, you know, there used to be an idea of there will be an abstinence violation effect, and so it emphasized abstinence so much that the people who relapsed, relapsed even worse than ever, so this is really not that big a deal. Found no evidence of that at all. When we looked at those other outcomes, like drinks per drinking day, or number of days drinking, or percentage of heavy drinking days, the AA condition did about as well, and sometimes even a little better than the comparison treatments. So it's incredibly good at promoting abstinence, but also does well on all the other alcohol outcomes. So it's not a one-trick pony. So even if someone, contrary to what you may think, and contrary to what AA itself might think, even people who do, in fact, continue drinking at some level seem to benefit quite a bit from AA, even if they never get to the complete abstinence. The cost findings we also dug into, and again, same replication, that it appears to produce substantial healthcare cost savings in every single study, not just the one that I showed you that I did. So this was a very positive conclusion. And it was very exciting, and it received probably more press attention than almost anything I've done in my career, nationally and internationally. The New York Times Upshot section did a really good story by Austin Fract and Aaron Carroll that stayed as the most read and most emailed story for three or four days. And I emailed the editor and I said, I can't believe that, there's so much news in the world. He said, he's never seen it before. But the response was so enormous to this work. And I read some of the many, many comments that were written on it. And one of the things that made me happy was seeing a couple of people saying, they'd always been denigrated for attending AA and believing that it worked, like they were superstitious and silly, that it meant a lot to them to say, no, actually it does work. It really does work. This is the most rigorous way we can assess a medical intervention. And by that criteria, AA looks really good. So we know that it's beneficial. The next question scientifically is what mediates those benefits? In other words, if you see someone in a terrible state going into an AA meeting and a year later, maybe they're doing extremely well, what happened in there? What's inside the black box? If A leads to B leads to C, we oftentimes just look at the A and the C, but we really wanna know what is the B? What is that thing in the middle? What is the special sauce and so on? So I've spent some time trying to figure that out with my colleagues. And this is one of our papers. Now, this is a structural equation model. I used to put it up with all the beta weights and gamma coefficients and all that in the audience, just kind of, I think, was stunned into a coma. So I've stripped this down to just the essentials, but the papers in Annals of Behavioral Medicine, the references are there. You can see all the math if you wanna see it. And this was a very large study of over 2000 people. We had an opportunity to assess as they were entering treatment, assess them a year later, and then a year after that. And so what we're looking at is, of those who got involved in self-help groups, who had reduced substance use, and then what changed for them along that path, so before they got there. And we found four things. First one is called active coping. That is how you deal with stress. So active coping strategies are things like, I made a plan to deal with it. I asked for advice from someone who was knowledgeable. I thought about different courses of options. I evaluated it calmly. Those are active coping strategies. Versus say, I pretended the problem didn't exist. I pounded my fist on the table, and I threw something, ineffective kind of coping. And the people became better at coping, and not just with addiction, with everything. Whatever stressful problem they have, they became better copers through their involvement in 12-step. Second, motivation to change. People became a lot more interested in becoming sober or stopping their drug use forever. Something that is said as a critique of AA and NA, and this, by the way, is all of them, not just AA, it's not fair. Some people say, oh, people go to that for years. That's because they're so motivated. But that's really misunderstanding and misrepresenting how motivation works. People don't wake up one day and say, I want to go to 10,000 AA meetings, and they have this massive motivation that then carries them forward for 10 years. Oftentimes, they don't even want to go to one, and they're there because their spouse is nagging them or complaining or something, and so they're going to go to this stupid meeting, and they think it's going to be junky, and then they hear a story that catches their imagination. Or maybe someone says, hey, you want to get a cup of coffee? And they kind of like them. They think, oh, well, maybe I'll try one more, one more. And it becomes motivating. It actually increases your motivation. So the reason that you see highly motivated people in recovery in AA and NA and CA five, 10 years out is because the organization nurtures and builds their motivation to change. And we saw that in this study over time. People, before they got there, they were becoming more and more interested in getting to a place of recovery. We also saw an improvement in general friendship quality, just questions like, are there people you can trust? Are there people you can count on? People were more likely to say yes. Again, not necessarily connected in any way to their addiction, but they did show a specific substance-related change in their friendship networks is that they had more people who they said, this person specifically encourages me to abstain or specifically helps me in my change efforts, and they had more people like that. And those are what we found anyway as mediators. We are not the only people to do this. There's been lots of great work done by lots of smart people. John Morgenstern, Leon Kaskudas, among many others, have looked at this mediational question. And some of the other things they found, some like ours, some of it different, but increased self-efficacy. So that's not just, I want to do this, but I can do this. I believe I can recover. I meant strength and commitment to abstinence. We found that. Other people found that. Active coping has been found by others. Social support effects also found by others. Leanne had a nice study showing that the people who had greater spiritual and altruistic behavior were more likely to recover. Sarah Seymour has also done a really nice paper on this called NAA Helping Helps the Helper. I hope I got that title right. But the people who did more service actually were more likely to recover. And then there's this phenomenon of switching friends out of their social network and switching people in 12-step programs in. Now, this is something, you know, in therapy, you know, you do care about your patients, obviously, but you can't become their friend for life. But of course, people can form lifetime friendships and do in these programs. And that's often helpful in that situation where many people that we work with clinically are at, which is they come in and they've got a problem, but all the people they hang out with also use lots of drugs and alcohol. Where do you find a social environment for them where that is not going to be a constant temptation? Well, a lot of people find it in these groups. And we looked at that in one study. We happened to ask people to enumerate all their friends after a year after they'd been through treatment. And we asked them whether or not their friends were in 12-step groups. And the sample split in two halves. And there was one group, about half the sample, where almost all the people they were hanging around with, their current friends and running buddies, were all in the program. And the other group had hardly any. And the same split was seen on the absence rate. So the people who were hanging around with a lot of 12-step people were more likely to be abstinent than the ones who were not hanging around with many 12-step people. This is so high in the year after treatment, where 90% of the people they're hanging around with, think of as friends, are in 12-step. It raises something that, for some family, can be something they don't like about 12-step. So, you know, expressed in the complaint, I heard once from a woman who said, he used to always be at the bar, and now he's always at AA. What difference does this make? And that sometimes people, that first year of particular recovery, is so intensive for people that sometimes families feel forgotten or left out and so on. But what I usually tell them is, what I see is that that is an intense experience, but people don't tend to stay at this level of super, super engagement. It's more like, you know, the chrysalis effect before you get a butterfly. And that as people get a stable recovery, they do tend to want to re-engage with family, re-engage with the things that their addiction ruined. But it just takes some patience to get to that point. So what? So there's the evidence. You know, we know that these things are effective. What are the clinical implications? What are the policy implications? Well, one thing I think we can see pretty clearly is what you do in treatment really matters, whether or not people get involved afterwards. Here's a study by Leanne Kaskudas, and this was done in what's called social model residential care, and she designed a course called Maze, Making Alcoholics Anonymous Easier, which was a psychoeducational program. I can't remember how many weeks it ran. I think it was like four. I'm not exactly sure, honestly. I don't remember. But, you know, it tells people what is the program, what's going to happen, what are the books about, you know, do you have any anxieties about it? Sort of something like what Chris Timko did, but on a longer scale. And she showed that when that was implemented, the one-year absence rates doubled for alcohol and drugs, which is amazing for a small, you know, psychoeducational intervention, because people were more likely to go to the groups. So that shows you, you know, as treatment, even if you only have a short-term contact with people, if you engage them and get them involved in these groups, you can really make your care outcomes much, much better. And when I say this, one thing I run into is often people saying, oh, yeah, yeah, we do that. We absolutely give people a brochure. So, you know, we're doing, we're following the evidence. And this is a study that just shows that that is not actually following the evidence. So this is a very small study. And it's in a way kind of crazy to design a randomized trial of a behavioral intervention with only 20 people in it. But yet, as you will see, they knew what they were doing. And it was people who were in already outpatient treatment for an alcohol problem. Half of them got what is probably the standard of care in the United States, which is there's this program called AA. You can go. Here's a list of meetings. Or they got an intensive referral where the person said, here's a list of meetings. And with your permission, I would like to right now call somebody that I know to take you to your first meeting. And in that intensive referral condition, the rate at which people actually did go to a meeting was 100 percent. Whereas with the standard referral, it was zero. Now, the difference between 100 and zero is obviously very big. And yet the thing that gives you the zero is probably the standard of care. So when people say, oh, yeah, we do that, we do that. We you know, if you're just handing a brochure, you're doing something that doesn't work. But just that little extra help over the threshold clearly has a pretty big effect. And I don't find this that surprising. It is kind of scary to go to a meeting, you know, and talk about your addiction in front of other people who you don't know and you don't know what's going to happen. Having that friendly face to to walk you over the threshold seems to matter a lot to people. So we should be doing this. We should be doing this. There are kinds of things like the Chris Land did to help people get over that threshold. And this is not just about psychiatry or addiction. This is something that can be beneficial across the health care system. I'll show you an example of that. This is a study by Rick Blondell, his ER doc, and he did this in Kentucky. And he's working now with people who come to the hospital through the ER after a alcohol related injury. So, you know, they're there, you know, as far as they're concerned. I had a car accident. I broke my femur. That's why I'm in the hospital. Nothing to do with my alcohol problem. So he compared three conditions. The control condition is people getting what normally happens in these situations in the American health care system, which is nothing. We treat the injury and no one ever mentions the alcohol. Then the second addition was a brief intervention. And you know what those are. But the physician would deliver it and do the whole thing about giving people the feedback and advice and support and some empathy and that sort of thing. About 15 minutes or so. And then the third condition was that brief intervention plus a peer, someone who was in recovery, would come in and basically tell them their 12 step story. So what Rick showed was that, you know, you do get in the control condition, even with no intervention, about 36 percent of people abstaining six months later, probably because the injury scared the life out of them. If you add the brief intervention that goes up to 51 percent and you add the brief intervention and the peer and it goes up to almost two thirds. That's a really big gain in effectiveness, 36 up to 64 with a pretty small intervention. And in terms of treatment or AA initiation after care, you get a huge effect. It goes up a bit when people get a brief intervention, but it goes up a lot when they get a brief intervention and that peer visit as well. So this shows something that I think we're often, you know, we often underappreciate ourselves. I think we absorb the stigma of the field and think we have to stay in our little space, you know, wherever that is, psychiatry or addiction or so on. But this just shows how important this is everywhere in the health care system and in the sort of prestigious parts of medicine, if you will. And so bringing people to recovery communities is just as important in the ER or in internal medicine or in family medicine or in pediatrics or anywhere else where people seek help for problems that stem ultimately from alcohol. Now, some people misunderstand when you say or I say, you know, there's a lot of evidence for these 12 groups, that that means everybody must go to a 12 step group. And if you don't like 12 step, there's something wrong with you. Do not read me that way, please. People with these with addictions are diverse. They need diverse things. And it is good that there are alternatives to the 12 steps because some people just don't like the 12 steps. They don't like the spiritual content of them or they just don't like the meetings or whatever. So it is good that there are alternatives. There are organizations that are not 12 step oriented are newer historically and they tend to be smaller, but at least most cities would have chapters of them. And most work right now do the work. Well, most of the work so far has been descriptive. Leanne Kaskudas has done some really nice work on women for sobriety. It was kind of a feminist oriented group, which was made by women who really thought AA was not good for women. And it tracks a generally college educated, obviously women audience. I've done some work of a group called moderation management, which for people who would not be at the severe end but do drink too much and it's to try to help them become moderate drinkers tends to be college educated people with a fair amount of social capital as you might guess certainly more social capital than you see the average person entering AA. But that's descriptive stuff so we haven't been trials of them. Sarah Zimmer has done a wonderful comparative study of just looking at cohorts of people who sought different kinds of help. And there's no randomized but across different groups, the ones I mentioned was life ring and smart recovery, really encouraging outcomes, encouraging data, which, you know, and I don't find it surprising because I think, you know, a lot of the change mechanisms you see in AA you would see in other groups to the shared journey, the empathy, the edification, the role modeling the installation of hope all those things should be happening elsewhere so if you if you want my bet I think these other groups work to even though they haven't been subjected to as rigorous evaluation, I'd be absolutely comfortable referring someone I cared about to any of them. The other point to remember is that, you know, if someone doesn't want to go to a group, it's not, it can't help them. So, if someone you know really can't stand any other group other than smart recovery then they should go to smart recovery that's the only place they're going to go. So, there's no sense trying to pound a square peg into a round hole right that that's where they want to go then, then good, let them do it rather than try to force them to go into a when they don't like it. John Kelly and his team are doing the, what's going to be the most rigorous study ever of smart recovery, and I've been done before he's got some funding from NIAAA and it's gonna be really exciting study and a prospective study. And I'm really, really keen to see how this works my bet is that it will show smart recovery work but data are data so we'll see. But I'm just glad to see that the, you know, data are maturing. And we're, you know, maybe get to a point I'd love to think you know that in 20 years we'll be able to say strongly positive things about all these alternatives as we can currently say about a. I want to mention also, I worked a bit with smart in the UK, I did a sabbatical over there. Smart seems to me for reasons I'm not going to get into here, kind of a good match for, for a lot of people in Britain to how the way it's structured kind of fits well it's it's smart as a cognitive behavioral theory theory based program doesn't have any spiritual content really emphasizes science is the ultimate authority, and the UK memberships tends to be pretty educated people. And I just thought this is something that I think might resonate for folks so we had Nick Heather myself had a grant which we shared with alcohol concern, and which is a charity inspired recovery UK where we trained people to be champions for smart and they went around to different sites in England, and, you know, total clinics are there's this organization called smart and here's how it works and, you know, would you be wanting to have a meeting here at the clinic, and you would you be willing to suggest your patients that they go with a fairly modest funds we were able to establish 18 groups and for four reasons around England. And part of what was fun about it is that only 12 were actually set up by us, six were set up in the normal organic way when groups to start to grow, like maybe two or three people who are driving half hour to get the group say why are we doing this let's just meet in our hometown. And then they started their own group which is exactly what you want me you don't want mutual help groups to be just an adjunct of a researcher or treatment agency you want them to have a grassroots basis that's So really like the fact that, you know, things took off on their own. And I think it's a pretty successful study with a very modest investment it was not a large budget at all, and got people engaged and it raised the profile of smart with professionals in the public so that that is something I think we could do more. So, I'll come to my conclusions now and then we can talk as much as you like. So first off, you know, I want to say very strongly 12 step group participation significantly reduces substance use and healthcare costs, something I would absolutely not have believed. 35 years ago when I first heard about these groups like, but you know the data are the data. And this is a causal statement, it is not associated correlated really is causal, we've looked at it and all these different designs is the most rigorous reviews and design support this is they really do work. Why do they work well some of it is psychological changes just like you would see in psychotherapy about things like motivation and self efficacy, and some of it is social which really can't happen in therapy itself things like I'm swapping out my old friends for some new friends. We need more research on non 12 step alternatives and we need support for those alternatives. Again, I just want to emphasize it's a diverse bunch of people who have this problem. There's some people who are never going to like 12 step groups, and they should not be shamed or, you know, bullied into going. You know, let's let's generate alternatives that they will go to. And let's evaluate those alternatives to make sure they're beneficial. And the last point, you know it's shown by like the smart UK study and investment in mutual help supportive infrastructure could benefit public health and reduce healthcare costs, whether that's by organizing campaigns or just better training for professionals to be aware of them. It seems like a very appealing, you know, payoff in particularly if it is true that all these groups are able to reduce burden on the professional healthcare system, then it's really an incredible investment to at least make sure that everybody's aware of and can take advantage of. I'm going to stop there and turn it over to any questions or comments that you may have. I think I can turn that off so we can see each other. Yeah. Well thank you so much Dr Humphries, and feel free to raise your hand if you'd like to ask your question yourself, or also if you'd like you can put it into the question answer box and then David and I can read it for you. I just wanted to, you were gonna say something. Yeah, I can say one point I mentioned alluded to the beginning and I want to bring up often comes up in questions and really important to think about is, well how do you handle the fact that there are people in a, who really do not regard buprenorphine and methadone as legitimate routes to recovery, and can be judgmental, you know, so like you know you're not really in recovery because you need that medication. So you have to be aware of that as possible. First off, I mean, we don't want to catastrophize because there are plenty of people who believe that who aren't in 12 step groups I mean there are family members may say that or, or, you know, coworkers could say that or sometimes sadly enough, even healthcare professionals sometimes say you're not really in recovery, if you're on those medications. But I think for most people, finding, finding groups that are tolerant and it's interesting there are more they tend to be younger groups, it can be really important so they don't run into that attitude. One of the interesting things about the literature on this is we have three studies now of people on buprenorphine, and who either do or do not go to 12 step groups and the ones who go to 12 groups have better outcomes than those who don't, even with the initial fight over the philosophy, it seems people are able to negotiate that, but it's something we have to be aware of, you know, clinically, that that can come up and it can be very painful and upsetting to a patient, understandably, when that tension arises. Another thing that we were just talking about just prior to the conference was the the new NSDUH National Survey of Drug Use and Health data, which showed that in 2021, I think 16.5% of the population in the United States had a substance use disorder and it was in the age group from 18 to 25. And this is just staggering data and we're also in an age where we have such limited resources. So this is so timely that this comes up that we have something that's free available. And I don't know just you could just comment a little bit on that. Yeah, no, it's a really good point and it's also super scalable. There are interventions that, you know, like we're doing a lot of work here at Stanford, I'm very excited about it with RTMS, you know, and maybe that will someday, you know, we'll have exactly the right protocol to help people with addictions with that amazing technology, but it's expensive and big and heavy, and you know it's, it's only going to be so available. So there'll be, you know, we maybe help individual patients but moving the population is not very conceivable. In contrast, when you have these self-help groups that pretty much, you know, takes what they say, two resentments at a coffee pot to start a new meeting, that they can cover an enormous range of locations and people. And then you can move those numbers. When you have millions of people in something, those terrifying numbers that you and I saw in the latest NISDA result, you can actually, you know, see a way to do something about that. And it's hard to do with expensive, high-tech approaches to addiction. Yeah, I think it's something that I've noticed in my practice for quite some time that anecdotally, people who engage in 12-step programming or self-help groups simply do better. And it's so refreshing to now have the data to back it up. And what I've found is that it actually turbocharges my capacity to help people by telling them, we have data that this helps. One of the things that I do is that if we say, oh, did you encourage them to go to AA? And that usually means is, oh, you ask them once, do you want to go? And then if they say no, it ends there. And so I think this idea of 12-step facilitation as a formal process is wonderful, but I think that we can actually do a much simpler version, which is just kind of pushing a little bit, asking why they didn't go, tell them about the data of how successful it is. You know, being that the kind of the purpose of this talk is about how we integrate that into psychotherapy. Yeah, so I don't see patients now, but when I was seeing them, I tried to de-stress the first meeting. So it's like, you know, this is not an arranged marriage, it's a date. Okay, so if you went on one date and you didn't like it, you wouldn't say, well, I guess I'm never gonna get married. You would say, you gotta go on a couple of dates before you can make that kind of judgment. So I'm like, why don't we try a couple of different groups at a couple of different times a day because you get different kinds of people in a couple of different parts of town and those can be really different. And I absolutely was insecure. And so it's just like, you know, these are just dates, right? You know, if you go to a bad movie, you know, you're out an evening and 10 bucks, but you know, you go to a bad meeting, you're only out in the evening. You know, let's just not stress. And then that kind of takes down the anxiety and also the sense of, if this doesn't instantly hit me in the face and save my life, I should just stop. And it's like, no, that was, you know, that was like a, you know, an all male meeting. It has a certain atmosphere. Maybe that's not so good for you. That was a, you know, here's a meeting where it's mixed and you like that, or here's a LGBT meeting and you like that, or there are people who are working class or professional class or whatever it is you're comfortable with or people whose lives are, whose addictions are like yours versus not, all that kind of stuff. And then, you know, and when it seemed that way, I think that helps people get out of the sense of, I have one shot and if it doesn't work, I'm never doing that again. Because that's not the best way to think. I also, you know, tell people there's like an app that's called Meeting Guide that people can look up. And so you give them some practical ways that they can kind of actually get to the first meeting and things could be helpful. And I think it's also really profound how much, how effective peers can be in the situation. And I'm just looking forward to ways that we can reintroduce that into more clinical scenarios because that data is really profound. Yeah, yeah, I agree with that. And I think peers can do things, you know, no matter how much I train, I can never be there in quite that same experiential way and say, I know exactly what you're going through because I don't at a core existential level. And I think there's also the leveling that happens when, look, I'm not a professor at Stanford telling you about cocaine. I'm somebody who has a terrible cocaine problem just like you, you know? So there's no way to feel put down by me in any way, I would try to put something down, but it's easy to feel those kinds of status differences when you have a stigmatized condition. And that seems really potent. And so I'm glad to see we've had this growth of recovery coaching and peers, you know, in recovery, you know, support services, but also in the treatment industry, because I do think they bring a magic that no amount of degrees can bring, as good as it is to have a degree and have training, of course, but there is something special there that I think we're better off with. In fact, I would say that's not just true of addiction. I mean, I think that like the incredible work of like widow to widow programs or breast cancer survivors working with current breast cancer patients, that kind of stuff is really, I think, very potent. We do have a question that just came in that I'll read from Jesse. Thanks for the question. Has there been any research into if there is a difference between efficacy between in-person and virtual 12-step meetings? Oh, what a great question. No, there hasn't. I will tell you what I see, and I would actually say this is also true of what I see in the therapy. Our department has gone, went entirely online pretty much during COVID, which is it's an utterly different beast to take someone with whom you have an established in-person relationship with and move online than to try to start the whole relationship online. So, you know, I talked to people in our department here and they've been going to their meeting for 10 years or whatever, and they see people online, they miss seeing them in person, but basically it's a pretty good experience for them. But they notice for that newcomer, it's just not as welcoming. You're sitting alone. There's no one to, you know, if something's upsetting, there's no one to put their hand on your shoulder. You can't say, hey, you want to get a cup of coffee, chalk a little bit, you know, that meeting after the meeting kind of thing all goes away. And so my bet is, and I can't prove it, my bet is that for new people starting that way is not as engaging as the in-person stuff. Now, I could say on the positive side, there are people who are very socially phobic, nothing to do with COVID, who would just never go to a group because the group's scared. The thought of speaking in front of a group is terrifying to them. Maybe for some of them, it would be the only way they would ever connect and that could be a good thing. But I think overall, I do worry about that, that lack of connection when everything is online. People have never had the experience of being together in person. So there's a term recovery capital. Have you ever heard that term? I think that we love scales and I think that there's some recovery capital scales. I was wondering if you can comment a little bit about that. Yeah, David Best has one, he's a very bright guy. So that's what I was mentioning about people who go to a moderation manager and have much more recovery capital. So the kinds of people who, their drinking isn't so bad that it's ruined everything. They still have, their spouse is still sticking around, they still got a job, they were able to complete their education. And the more you have, the more likely you are to be able to recover. And part of what AA does is it helps you build this recovery capital. So, yes, there is this focus on non-drinking, but then there's also focus on going back to people you have harmed and making things right and rebuilding the network you had where people cared about you, but then they just got so upset or angry or hurt that you've shattered that relationship and helping them put it back together. A lot of people find jobs in AA. It's something I never actually studied, but I just noticed that. It's like, how did you get this new job? Well, a guy at a meeting said they were hiring down at the plant. And so I went down to the plant and I got a job. That's capital, right? There's a reason to stay sober. I've got a job that I like. So I think it's pretty masterful for that. And because people can stay involved for so long, there's more potential for that than we can typically provide in the treatment system because we don't usually get that long to be with patients anymore. Yeah, and in my practice, I have a bullet point at the end of every chart. What's this person doing for recovery capital? And I'm encouraging our fellows to insert that into most of their notes. Great. Yeah, it's nice too, because it's a strength-focused thing as opposed to just looking at pathology, yeah. Some other questions. I'll ask the next one. Jeremy Herschler says, would you please say something about the 13th step behavior and predators who try to get those in early recovery in romantic relationships rather than work on recovery? Yeah, so 13th stepping is a term, a jargon in there for where somebody tries to manipulate the sponsor relationship into being a sexual relationship. Explaining, pointing. And that certainly happens, but it also happens, of course, with professionals too. I'm embarrassed to say, but when I open up my newsletter from the State Psychological Association each year, there are always cases like that. And it's a complete betrayal of a person's trust and it's very harmful. So you always want to be on guard for that. And I think one thing you can help your patients with, particularly if they have a history of not being too wise in picking who to trust, is to talk through the sponsoring decision. Who is it you think you might ask? What is it about them? Have you asked other people about them? What do they do that inspires trust? Make sure they make that decision in a safe and intelligent way. The question that I often get from people when they're learning about AA and whatnot is, are there any side effects to this or potential dangers of recommending this to people? Yeah, well, 5 million people on the planet who are in AA. 5 million people can include a lot of people who are difficult, angry, destructive. I mean, there's no guarantee that you will not meet people who are destructive in AA. I mean, it can't be any such guarantee. It is also true that sometimes people get nagged, but not so much by the members in the program who are pretty okay about, if you don't want this, then you don't have to come here, but sometimes by people around, AA has such a reputation that maybe you don't like AA, maybe it's not working for you but your doctor is convinced or your spouse is convinced or your boss is convinced that you must do, or the judge is convinced that you must do this. And then you have people full of resentment, understandably, grinding their teeth through meetings they don't wanna be at and that's bad. Sometimes the criminal justice system exploits AA. So you have a meeting with six people who really wanna be there and a bus pulls up from the county farm and lets 30 probationers out saying this is our county's alcohol treatment program for people on probation. Well, that kind of ruins the character of the meeting and it's unfair to the people who are there because they want to be there in recovery. There's really no other place where we do that, where the criminal justice system doesn't wanna pay for something. It doesn't force voluntary associations to suddenly become an arm of the system, but that just happens sometimes. And that is, I think, unfair to everybody. One of the things that I do in my practice is when there are some people who are deeply engaged, they'll know which meetings are good and which aren't. And I'll keep a little log of which ones are good so that you can direct people in some direction. Yeah, that's right. And also even among good meetings, there's a lot of variety. So some meetings are very spiritual meetings. They start with a meditation or reflection period. Others are very intellectual. Some are kind of macho. Some are more therapized in how people talk. People speak different languages in meetings. There's a huge network in California of Spanish-speaking. AAs and people may be more comfortable with that depending on what their language is. Smoking, non-smoking. Although I guess smoking is pretty hard to do anymore, but still there are some still smoking meetings. And so that's where that match issue comes in. Again, even when the meeting is pretty good, it may not be good for that individual. And so that's why I like the dating analogy. It's like, well, I'll just try a couple and see what you find. Another question. Clearly peer support is important in referral to treatment. And I wonder how to easily and cost effectively expand this throughout the medical system. Is in-person peer involvement a key to this success? Could recorded video peer narratives be as useful? That's a good question. I mean, we all know people who have been moved to change their behavior based on movies, novels, art. I mean, sometimes people are able to make that connection that way. And with no actual human, perhaps be someone who's not even alive anymore, but they read a novel. It's like, wow, that really made me see I needed to seek treatment for depression or whatever. But I think most people, the human connection is pretty important. Most of us are not great novelists or great artists or musicians, right? So that being there is really important. And I think this is a leadership issue. How do you do this across medicine? You have to have buy-in at the highest levels. If we wanna get out of our bubble particularly and be taken seriously in the input of peers and other parts of the healthcare system, that takes leadership of our bosses, our deans or our hospital directors to say, this is really important to me and to our care system. We all know, or we should know that everyone is treating addiction. They may not know they're treating it, but you cannot be a healthcare provider in the United States and not encounter addiction. That's just the way it is. And we know that peers are very valuable. So we are going to have a peer program, and you are all going to accept that, that we have peer program. And at least the healthcare systems I know of mostly are okay with that. I mean, most of them volunteers of various sorts are pretty common, I think, in most healthcare systems. So I think the space is there. Sometimes it may just take some leadership or some energy by us to advance the evidence to our colleagues and just persuade them, this is something that would help you do your job better. One of the things I have learned about us and other specialties is we often go to, you know, cardiology or dentistry or pediatrics or whatever, and say, here's how you can help with our agenda. Here's what you could do to treat addiction more. And most people are not that enthusiastic about someone walking into their office and saying, hey, how would you like to do my job too on top of yours? But if you go and you say, this can help you be a better cardiologist, this can help you be a better pediatrician. You know, you achieve the outcomes you're always trying to achieve. Well, if you knew something about addiction and you could do something with it, it would help you achieve in the terms that you have chosen for yourself with the job you've chosen rather than the one I've chosen, because, you know, you and me are different. And so I always try to lead this way. You know, like if I'm talking to, as I was, and I want to go talk to the anesthesiologist, I said, you know, if you just screened people, you would have fewer negative responses to anesthesia on the table. You would have a lower surgical complication rate. And I know you really care about those things. So how about screening people for substance use, everybody who comes into the surgical suite? That kind of argument, I think, is far more effective. How would you like to be an addictionologist? Well, if they wanted to do that, they would be one of us. So we need to think about it from their point of view. It helps them do their job better. Yeah, it was some pretty profound data that you presented about how, you know, this can really relieve a lot of the economic burden of people with addictions. And so being able to present that data to leadership, we would think we'd be able to have some resources directed, you know, towards it. One of the ways that I have been trying to convince people to do this is to, like, for example, I also work in the emergency department, is to have like, you know, the med techs, which is, you know, a position that requires maybe a few months of training is you can actually have a program where you encourage people who are already embedded into the system to selectively try to hire people who are, you know, peers in recovery. And then it must be like a double efficacy there. That's awesome. Yeah, we've just started with peer navigators in our ER here and, you know, it's, they're actually really cherished. I mean, and I think it's, we all know, if you're, all of us in this field, if you hold your hand up and say, I like addicted patients, it was like, wow, that's great, because I don't know what to do, or I don't like this population. You know, I love you, thank you, yeah. Well, I just wanted to thank you for taking the time to join us today. Really enjoyed it, nice to meet you all. Yeah, so thank you again, Dr. Humphreys. And, you know, next month we'll be talking about, David, do you remember what's next, what's next on? I think that's smart recovery. Oh, yes, right. Tom Horvath talking about smart recovery. That'll be good. Yep, and just a reminder, I missed this in the beginning, you can log on to the website to claim credit, logging into the portal, complete the evaluation, and then you'll be prompted with how to claim your credit. And again, Dr. Humphreys, thanks very much, very useful and a lot of great information and evidence to kind of back up what we should be doing with our patients. Thank you. Thank you. You're welcome.

self-help groups

Alcoholics Anonymous

addiction recovery

abstinence

reduced substance use

improved mental health

cost savings

12-step programs

healthcare costs

peer involvement

peer support in healthcare systems