<v ->Hi everybody, I'm delighted to be here.</v> My name is Dr. John Kelly. I am a professor of psychiatry at Harvard Medical School and the founder and director of the Recovery Research Institute at the Massachusetts General Hospital in Boston at the Department of Psychiatry. I'm delighted to be here with you. My topic for today is on mutual-help organizations and related clinical interventions designed to link patients with substance use disorder to these free, ubiquitous resources in the community to help patients enhance the chances of remission and improved quality of life. So I do not have any disclosures, in terms of the roadmap for this talk today. Here it is. I'm going to give you a little bit of background and rational as why it's important to address these endemic problems and why, how mutual-help organizations fit into this overall effort to address these endemic problems related to alcohol and other drugs. I'll talk about groups like AA, which is by far the largest, but I'll talk about the variety of mutual-help organizations that exist for the benefit of individuals suffering from these conditions. And I'll be looking at the research and science that has been conducted on the benefits attributable to these kinds of resources that people can utilize. And look at how they work, as well as for whom they work. And also in the last segment today, I will talk about clinical interventions designed to engage patients who have these disorders with these free community resources to enhance the chances of long-term remission, as well as reduce healthcare costs. A few definitions before we begin. I know many of you viewing already know many of these terms, but some of you will not, so I'm just going to go over a few different definitions regarding substance use, substance use disorder, and addiction, as well as recovery and remission, which I'll be talking a lot about today. And as you can see on this slide, there are different gradations of substance involvement and substance impairment, which we associate with different disorders and addiction. There's a broad spectrum, of course, of alcohol and other drug use from use, intermittent use, casual, low intensity use to very high intensity, very frequent use, which we normally associate with harms and hazards as well as addiction, as you can see here. There are different terms often used to describe the spectrum of alcohol and other drug involvement, starting with just pure use, of course, as well as a misuse or harmful use and hazardous use, which can cause injuries, accidents, as well as toxicity related illnesses. Through to disorder, which is a slightly different facet of substance use that involves a syndrome, that's a compulsive use typically of varying degrees, again, of involvement and impairment. Right now we have, with the DSM-5, we have a single category with 11 total symptoms, which constitute this syndrome. If you have two or more of these symptoms, you are in the category, you meet criteria for a substance use disorder. But very importantly, there are different gradations within that single category, of course, from mild, to moderate, to severe, depending on the number of symptoms that are met, as you can see here. Remission is a specific definition. It's having no more than craving in, you know, as part of the course of the illness. So you can meet criteria for craving, which is one of the 11 symptoms, but if you meet more than just craving, then you're not in remission. So until you can remove all those symptoms for a period of 3 months for initial remission and then 12 months for sustained remission, then you're in remission. Addiction is another term that we often use generically, of course, to describe the whole spectrum of problems. But we also more technically use the term addiction to describe a pattern of compulsive use, despite harmful consequences. And this is really the severe end of the spectrum. In fact, when we talk about severe substance use disorder, we are talking about addiction, that is really synonymous with addiction. When you talk about mild and moderate, then you're still, people are still getting into problems and difficulties. They may have injuries, accidents, social problems related to their alcohol or other drug use, but addiction is typically the severe end of the spectrum, where we're talking about severe substance use disorder. So hopefully that is a little bit clearer. And recovery is a term that we hear often, of course, in relation to various things, but particularly with substance use disorder. We talk about people in recovery and being in recovery, of course. And you can think of it as a kind of a process of change through which individuals improve their health and wellness and live a self-directed life and strive to reach their full potential. So that broad definition doesn't necessarily encompass abstinence or even remission, but rather it describes a process of change to which people are moving in a direction towards greater health and wellbeing. And it may or may not include recovery in abstinence, although it often does. Recovery support services, which I'll be talking a lot about today, particularly, of course, regarding mutual-help organizations, which is by far the largest form of recovery support services worldwide and in the United States. Services typically that operate outside of the clinical realm, so these are often community based services like mutual-help organizations, peer-led organizations. They can take the form of recovery residences or recovery community centers, recovery cafes, collegiate recovery programs, recovery high schools, all these different support services designed specifically to provide support and empowerment for people who are in the early stages of remission after medical stabilization. Again, these are not intended to supplant clinical services, but rather to augment and extend our clinical services. There are four dimensions of recovery that are espoused by SAMHSA, which is health, home, community, and purpose. And you can think of these as kind of as the primary kind of facets of recovery health, of course, you know, hopefully removing the substance or reducing the substance use to a point where it's causing much less harm. Having a safe place to live in terms of home. Purpose, having meaningful activities that people can engage in. And community, having social networks that can provide support, friendship, love, and hope, of course. And then, recovery capital is a term that's often used these days borrowed from behavioral economics. But, of course, the idea of capital is that it's kind of like a bank account where, but in this case it's really a resource. All the resources that can be used to tap into. They can be internal resources, like my own motivation and ability to cope with the demands of recovery, to social services and other kinds of things, finances, jobs, housing that can be utilized to support one's recovery. And that's known as recovery capital. So focusing in more squarely now of my talk today is mutual-help. So these are kind of the key points in answer to the first question, which is why should we focus clinically on understanding the utility of mutual-help organizations? Well, one of the important things is that our clinical services, while they can be very potent and valuable in moving the needle as it were towards remission and recovery, they are often time limited and more expensive. And we can augment and support our activities in the clinical realm by utilizing these often free resources in the community that have now been shown to support remission over many years and reduce costs. So we do know, for example, that achieving remission and the path into remission for these disorders can take a while, can be a bumpy ride. Most people do get there as I'll talk about. Addiction can remit, but staying in remission requires ongoing support, encouragement, accountability, all these things that we benefit from as human beings to stay the course to keep involved with something over time, of course, is key. Whether that's a diet, or exercise, or addiction recovery, it seems that all as human beings, we benefit from this scaffolding that can be provided by things like mutual-help organizations. Happy to say that we now have a variety of mutual-help organizations available in most communities as well as online. I mean the online now resources, which have really, we've been driven to courtesy of COVID, that's one of been one of the silver linings of COVID has been really, you know, an eyeopener for us all in terms of realizing the value of telemedicine, telepsychiatry, telerecovery services, as well as online mutual-help organizations that can be accessed all over the world to benefit people. Mutual-help organizations as a more formal definition are peer-led, typically peer-led and peer run. The most famous, of course, would be Alcoholics Anonymous. And then all the other 12-Step organizations, which have utilized that same 12-Step template to address other drug epidemics as they've come along, like opioids, or cocaine. or stimulants, other stimulants like methamphetamine, or cannabis. But they're essentially peer-led entities and intended to address these disorders to help people move into remission, gain recovery, using the lived experience of other members. So this can, of course, coming across others who have been through it or on the other side of it can instill a lot of hope for people who are suffering and feel stigmatized by these conditions. Can find a sense of common purpose, common value, common suffering, and also look to others to see that life looks good on the other side of these disorders through observing their peers in these mutual-help organizations. So that's one of the primary functions of exposure to these entities. They can really help instill hope and provide support. They're nearly always populated and run by peers. I think one exception is SMART Recovery, which stands for Self-Management and Recovery Training. I'll talk a little bit more about that in detail in a minute. But, this is a cognitive behaviorally oriented peer support network, but it's also run by trained facilitators, who may or may not be in recovery. So that's a little bit of an exception, but the intent is the same, to facilitate peer interaction and peer involvement with people with lived experience to again instill hope and provide a sense of common universality, common purpose, cohesion, and other therapeutic factors. Most of of the mutual-help organizations available are geared oriented towards abstinence. Some allow moderation goals, like SMART Recovery. And some, one is explicitly moderate moderation focus that's known as Moderation Management. It's meant not for alcohol use disorder, but rather, or at least for mild and moderate alcohol use disorder or otherwise kind of hazardous, harmful heavy alcohol use without reaching the criteria for addiction to alcohol. And the idea there is to help people to moderate their alcohol use and to be able to improve functioning and wellbeing. I think it can be helpful to think about the framework for understanding different interventions when we think about these disorders. And, of course, we can look to the stages of change as a useful framework on which, or from which, we can overlay different interventions that can help people move through these stages towards better functioning and remission. And you can see here across the top, these different stages of change associated with substance use disorder, like pre-contemplation and contemplation, where a patient may not be that aware or that motivated to change at the current time. Towards preparation and action where people are motivated, they recognize as a need for change, they want to do something about it, and they start taking steps. Through to the right hand side of maintenance, where people are trying to maintain those gains made that produce that initial remission. And typically, we need the scaffolding and the building materials to help them maintain that over time. And as you can see on the bottom, the different interventions that can be helpful at different stages of change. For example, when somebody's not ready to change harm reduction, motivational interviewing can be very helpful to mitigate adverse events, like overdose or transmission of other infectious disease through helping patients through motivational interviewing, to consider the benefits, pros and cons of changing, or staying the same. Through to cognitive behavioral therapies. And then 12-Step, so-called 12-Step facilitation therapies, which have now been designed and developed, tested and shown to support patients as I'll talk about in more detail in a minute. To link patients to groups, like AA, and support remission over time. As I mentioned in the beginning, one of the rationales for the clinical and public health utility of mutual-help organizations is the fact that these disorders tend to have a chronic course which can last many years, particularly those who have, who are on the more severe end of the spectrum as shown here. These are patients with addiction that is severe substance use disorder. And these are taken, these numbers are taken from adults clinical samples. What's shown here is that it can take a number of years to get into initial remission and then to get into stable remission. If you look on the left hand side, you can see it takes about four to five years after people meet criteria for substance use disorder before they start seeking help. Now, part of the delay, of course, is because of the stigma and fear of discrimination that people feel if they were to disclose or reach out for help. So that can delay help seeking. Once people do start to reach out and and access resources, it can take about eight years of trying before people get into full sustained remission, that's 12 months of abstinence or without symptoms, other than craving, as I mentioned before. And it can take about four to five treatment or mutual-help episodes to get there. That's quite a long time. Also, noteworthy on the right hand side here is that five year marker, that's the number of years on average it can take before the risk of meeting criteria for substance use disorder in the following year drops below 15%. Why is 15% important? It's because that's the annual risk of meeting criteria for SUD in the general population. So to be no more likely than anybody else in the general population of meeting criteria for substance use disorder, if you've already had it in the following year, can take up to five years of stable sustained remission. So in other words, we need to provide some kind of service or support across that five year period after people achieve that first year of sustained remission to help those individuals stabilize and be no more likely than anybody else in the general population of meeting criteria for a substance use disorder. That can take a number of years of support. And this is where mutual-help organizations have shown to be particularly helpful. And you also on the right hand side here, you see that purple box, which shows the remission rate for substance use disorder in the general population. And this is good news, these tend to be good prognosis disorders. It can take a number of years to get into remission, but the most likely outcome for substance use disorder is sustained remission. And we can accelerate the time to remission and the time to stable remission by providing access to these recovery support services that can help build recovery capital. There are a number, as I mentioned, a number of these different recovery support services now available. There are many different mutual-help organizations alone. We have not just 12-Step, like AA and NA, and CA, and all the other 12-Step organizations, but a variety of other mutual-help organizations, like LifeRing, Women for Sobriety, Refuge Recovery, Celebrate Recovery that have emerged in the last 30 years and are starting to grow to provide different options. There are also peer-based recovery support services or recovery coaching, as I mentioned, recovery residences. There are recovery community centers and recovery supports and educational settings. But today I'm going to focus on mutual-help organizations. They've existed for a long time. There's been a natural inclination for people with these particular types of psychiatric disorders, that is to say substance use disorders, alcohol and other drug use disorders, to seek help a refuge among their peers. And this has been going on for at least a couple of hundred years in the United States and in different countries. There was a very famous example, precursor really, to AA called the Washingtonian movement, which was in the 1800s, which grew very rapidly, kind of a forerunner to 12-Step, to AA, that expanded rapidly and was by all accounts very helpful and successful. It dissolved because it got involved with other kinds of issues of the day, unrelated to addiction recovery. In the 20th century, in the 1930s saw the growth, of course, in birth of Alcoholics Anonymous, which grew over the next several decades to cover most nearly every area in the United States as well as around the world. There are roughly 80,000 meetings in North America, and they are highly ubiquitous resources. Some of the advantages, as I mentioned of these are that they are widely available, they're flexible, they're accessible, they're free, just through voluntary donations. So you don't have to have any money to utilize these. You can access them at times when professional help is often not available, like on holidays, in the evenings, or weekends, when relapse risks can be particularly high. And they provide access to a flexible social network of peers that can operate between meetings and this is one of their main benefits. This just highlights some of the different types of mutual- help organizations that are now available. There are many online as well, not featured here, but these are the largest. As you can see here, many of these have been going for quite a while. They have varying degrees of availability. By far, the largest, most influential has been the 12-Step ones like AA because they have been around the longest and they have successfully disseminated into communities in most communities and have had staying power in terms of lasting and growing. But you can see also the growth of other mutual-help organizations. Notably, SMART Recovery, LifeRing, Women for Sobriety, as well as Refuge Recovery. There are other mutual-help organizations designed specifically for patients with severe mental illness, as well as substance use disorder. These groups here like Double Trouble in Recovery, Dual Recovery Anonymous, tend to help patients, particularly, with schizophrenia and substance use disorder, or other severe mental disorders, typically that have reality testing issues along with substance use disorder. And I have found in working with various patient groups, that patients with these kinds of psychotic spectrum illnesses, as well as severe addiction, tend to benefit from these groups. People with PTSD, major depressive disorder, tend to benefit as much in regular groups, like AA and NA. Other groups, of course, have emerged based on the 12-Steps of AA that are addressing other kinds of compulsive disorders shown here. I think I've said this already in so many words, but again, some of the key aspects of the utility of these services is that they can provide this scaffolding over time, which is often necessary for many patients who have been particularly affected by these disorders. There is a physiological vulnerability that can undermine recovery attempts, that can induce craving, and that can be overwhelming in terms of many patients facing these challenges. So providing this flexible, accessible, low cost community-based network can be very helpful for helping people sustain these gains over time. They can also provide and act as a early warning system because oftentimes peers in recovery know the name of the game. They can point out to vulnerable people when they may be showing signs of relapse before they're picked up a drink or a drug so that they can head off a potential disaster or relapse or even premature death. At the bottom here, I note that as I mentioned before, recovery includes access to and ongoing medical treatment. It's not in place of, for some patients, recovery support services alone can be helpful without going to treatment many people do do that, but ideally we would want to be augmenting our medical treatments with providing linkages to these free, ubiquitous, indigenous, ongoing community-based services. Some challenges of mutual-help organizations that obviously they're not professionally run, these are freestanding, independently organized and peer run based on lived experience. And so this can create kind of a culture clash between our clinical services sometimes. And these community-based services. For example, one of them has been on to do with particularly to do with agonist medications. So things like buprenorphine and methadone historically have been more stigmatized across the board, but also even among recovering persons. And particularly in groups like Narcotics Anonymous who may welcome people on these medications, but they disallow full participation while they're taking methadone or buprenorphine because they view those as still using to some degree an opioid, which, of course, is true, but they consider that to kind of be not full recovery. Now, despite that, however many patients with opioid use disorder use and benefit, have been shown to benefit from, groups like NA, Narcotics Anonymous, despite those barriers. So there are groups, subgroups within that very broad network of meetings that have been shown to be medication friendly, so very supportive of medication use. So it's not a universal problem, but it is a challenge that may be faced by some patients. But for those patients who can find, you know, supportive peers in the meetings and supportive sponsors can benefit from utilizing these resources who are taking agonist therapy. So that's good news. So what do we know about the science on groups like AA and other mutual-help organizations? Well, what we've learned particularly in the last 30 years is a great deal because the rigor, the quantity and quality of the science on these things have really increased. We now know that mutual-help organizations, particularly, Alcoholics Anonymous for alcohol, for severe alcohol use disorder, confer benefits that are on par in magnitude with professional interventions when patients are linked to them. Interventions that promote mutual-help participation, like 12-Step Facilitation so-called, often produce superior outcomes and higher rates of remission. I'll talk more more about that. Participation in mutual-help organizations also reduces healthcare costs by reducing emergency room visits, overnight stays in the hospital, as well as other kinds of professional counseling. And 12-Step Facilitations that increase participation in groups like AA Produce have been shown to produce these better outcomes because they mobilize mechanisms that are also mobilized by formal treatment, but they're able to do this over the long term in the communities in which people live. In other words, going to AA works, helps to sustain remission, because it boosts cognitive behavioral coping, it boosts self-efficacy, it reduces impulsivity, it reduces craving. So we've now uncovered some of the mechanisms through which these groups work. I'll talk more about that in detail in a second. When we look over the last 30 years, the reason why there has been this rapid increase in the quality and quantity of evidence in support of the clinical and public health utility of AA, in particular, is because of this call 30 years ago from the Institute of Medicine of the National Academy of Sciences, which called for more research on AA in its book, "Broadening the Base of Treatment for Alcohol Problems", published in 1990. As a result of that call for more research from this very prestigious body, the National Institutes of Health, the Department of Veterans Affairs, funded many studies, many dozens and dozens, in fact, of clinical trials linking patients to AA. Bill Miller shown here and Barbara McCrady were prime movers in this regard, in terms of convening a convention in New Mexico, publishing this volume in 1993, which documented the research up until that time and creating an agenda for the next 25, 30 years, which has produced, as I mentioned, dozens of clinical trials, as well as naturalistic studies and other studies of mechanisms of behavior change on AA. This graphic highlights the different flavors or different kinds of therapies that have been tested to link patients with severe alcohol use disorder to Alcoholics Anonymous. And you can see there are different types. Some are standalone therapies, some are integrated into other therapies like CBT, as a kind of a combined therapy. Others are modules in a intensive outpatient program, for example, one of which may link patients to AA, talk a lot about AA or other groups. And other ones down the bottom left are kind of modular appendages where you do whatever you normally do in your treatment and then you link patients usually with a warm handoff to an existing peer to help them get connected to these resources. We published a review in the Cochrane Library summarizing the evidence over the last, particularly over the last 30 to 40 years in 2020, you can see it here on the screen. Surprisingly, what we found in this review is that when patients are systematically linked to AA by a clinical provider using a manualized approach and subjected to the same scientific standards as other clinical interventions linking patients with alcohol addiction to AA produces as good, or in cases of remission, higher rates of sustained remission in the realm of 20 to 60% higher remission rates for patients linked to AA compared to just receiving something like CBT or MET alone. The other thing to note is that not only did it produce higher rates of sustained remission across time, but it also dramatically reduces healthcare costs. So patients are doing better for less money. And you can see here, this is just the top layer of evidence, the most rigorous trials were all manualized RCTs showing the relative benefit in yellow relative to comparison conditions of 12-Step Facilitations. These are clinical interventions linking patients to AA with severe alcohol addiction, producing these 20 to 60% higher rates of remission across up to three years after the intervention. And as I mentioned, you know, the healthcare cost savings are substantial in the realm of $10 to $15 billion per year if we were to link patients with alcohol addiction to these free resources during treatment. We've also learned a lot about the mechanisms of behavior change through which these interventions work. And these are depicted here. These are the empirically supported mechanisms of behavior change that have been found to work the way that AA works. So in other words, how does AA work? It produces changes in the social network, which in turn expose people to recovering people with lived experience of successful remission recovery that has been sustained for many months, years, and decades. That in turn, reduces exposure to high risk environments where alcohol or other drugs may be present. And it also helps peers who are seeking recovery to boost their cognitive and behavioral coping skills, their self-efficacy, it reduces craving, it reduces impulsivity, and it increases spirituality, which can help people to reframe stress. Now, when we think about mutual-help organizations, as I mentioned, there isn't just one flavor, there are a number of different flavors now. AA is certainly the biggest and the largest and the oldest, it's also has the strongest evidence base in terms of its clinical and public health utility. We have a very clear empirical picture now that AA works when we link patients to it. Patients can do better, have higher rates of sustained remission. But, not everybody wants to go to AA. So what do you do when someone doesn't want to go to AA, or 12-Step groups in general. I often make this analogy of the importance of providing other kinds of resources. I often ask audiences, you know, do fitness centers keep people fit? Do fitness centers keep people physically fit? Well, the answer is, yeah, of course, they do if you go and you work out regularly, you'll stay physically fit, but you got to keep going and stay engaged. Now, fitness centers know this, so what do they do? They know that they work, and we all know that they work. But the challenge is how do you get people engaged in physical fitness activity? How do you get them to come back into your fitness facility? So when you walk into a fitness facility, you don't just see 40 treadmills and that's all they got. Rather, you see 40 different kinds of classes, pools, courts, all kinds of activities and things designed to attract and engage different people in some kind of physical fitness activity. Let me extend the analogy here, do mutual-help organizations keep people fit for recovery? Yes, they do. We have very strong evidence that groups like AA help support remission over time. This is good news. But again, you have to want to go and you have to keep going. So the challenge again is if someone doesn't want to work out, even though AA may work, if someone doesn't want to use that piece of recovery equipment as it were, in terms of AA, what else can they use? And so historically, we've been limited to just one option that is to say 12-Step. Now we have a number of different options, a number of different pieces of recovery equipment, if you will, to extend the fitness metaphor, whereby more people hopefully can find something via one of these mutual-help organizations to get involved in some kind of recovery process. Now, it may be that it's not as potent or as strong as the effects from AA, may be the cross trainer of recovery. Or they may be these other groups we don't know, but we don't have as much information on these other groups in terms of the kind of benefit they confer. But you know, it's important it gets people involved in something that will move them in the direction of health behavior change. So this is why, of course, there's a number now of these different entities that have emerged and grown online as well as in person. Many of them shown here. There are different, as I mentioned, different formats, you know flavors, emphasis, focuses. Some are just for women, some are more cognitive behavioral, some are more spiritual, some encompass moderation, some are are online like the Luckiest Club. So there are a number of different aspects, number of different types of these disorder, sorry, mutual-help organizations now that are available. So you can think of this as kind of a fitness for recovery gym. It's like, where do you go work out? Can you find a piece of equipment recovery kind of equipment that fits your particular level of involvement at that particular time? This is really good news that we've got these different options. And we have an emerging evidence base showing that when patients themselves self-select one of these, just like in a gym, who would self-select a piece of equipment for themselves to begin to work out on. What we are finding is that people who self-select into one of these mutual-help organizations do as well as each other. So there's no differential benefit, it's just a matter of finding something that you can use to help you in your recovery journey. I've mentioned a lot about Alcoholics Anonymous because that's where the majority of the funding has gone because AA is by far the largest, biggest, the most influential. Alcohol use disorder is the most ubiquitous substance use disorder, of course, 75% of substance use disorder cases are alcohol use disorder. So necessarily that has taken kind of the front burner of research and evaluation so far. But, other drug use disorders have also been examined in relation to their mutual-help participation and derived benefits. This was a review published in the Campbell Library, which in Campbell System, which is similar to the Cochrane Library, it's very rigorous in a very similar way to the Cochrane Library reviews. Ultra transparent and rigorous. This also showed that when patients are randomized to receive a linkage to distinct to groups like CA, Cocaine Anonymous, or Crystal Meth Anonymous, or Narcotics Anonymous, patients do as well as other kinds of interventions and do a little bit better when you're talking about continuous abstinence. Similar to the findings on AA, but we have much more to learn regarding other 12-Step organizations for drug use disorders. And what about mechanisms? How do they work? What have we found about how these groups confer benefit? Well, this causal chain has been supported in that a linkage, a clinical linkage. As clinicians, if we introduce the idea of AA, for example, talk about what AA is, what it does, what a sponsor is, prescribe attendance, they'd recommend that you go to three meetings this week, come back and keep a log of your experiences. We'll talk about it next week. The reason why those clinical linkages produce better outcomes, as I mentioned, 20 to 60% higher remission rates, over for up to three years post-intervention, is because they get people to go to AA. So it does work. So, clinically we can influence the chances that someone will have better outcomes by getting them to go with an AA at random. Okay, so just at random, when we look at the randomized data from these 27 clinical trials that I mentioned in the Cochrane review, we find that patients who are linked tend to go and those who go do better. Then the next question, of course, is, well, how does AA control that benefit? And as I mentioned, there are a number of ways now that have been shown that AA benefits people including these ones, which I just mentioned. The other thing that's been very interesting in looking at the mechanisms research is that the way that patients who are linked to AA have been shown to benefit. Again, this is all the research on AA because we haven't gotten anything else at the moment, but I think we can make some inferences based on the research that we have on AA, because I think most of these groups operate in very similar ways, is that when we look at the mechanism of behavior change research from AA participation, we can see that patients benefit in multiple ways simultaneously as shown here. But also, different patients benefit in different ways. Now, here for example, is looking at men and women. The question asked here is, do men and women benefit to the same degree and in similar or different ways than men, who are participating in AA? Now, what we found in this study was that, and this is a 1700 patients, clinical patients with alcohol addiction, we found that men and women benefited to the same degree. So they got the same degree of relapse prevention benefit. But the way that men and women benefited from AA participation differ dramatically. Look on the right hand side here, you see that blue segment among women there in terms of relapse prevention risk, relapse prevention. You can see up in this blue segment that one of the main ways that AA benefited women was by helping them boost their confidence and to cope with negative affect when experiencing relapse risk and also by reducing depression. You see that? That's over half the effect of AA benefit for women was by boosting their confidence in coping with negative affect and reducing depression symptoms. And look for men. For men, that was not significant. Neither depression nor negative affect self-efficacy. What was different for men was that the way that men were benefiting from AA participation was by boosting their social self-efficacy, their ability to cope with high risk social situation. You can see here that that was not true at all for women. Really interesting differences. Ostensibly here, the same intervention. You've got AA as a broad stroke, similar intervention, but the way that different patients may be utilizing and benefiting are different depending on their particular life context and needs. So, for women who suffer from more negative affect at higher rates in the population and in the recovering population are utilizing AA to help them prevent relapse via helping them cope with negative affect. For men, the biggest risk factor for relapse for men is social factors. And for men, AA is helping them prevent relapse by boosting their confidence in coping with these high risk situations without resorting to alcohol or other drug use. So this is, I think, really interesting when we look at the mechanisms of behavior change. What are the relative, what's the relative importance of these mechanisms? And then do these mechanisms differ by different patient characteristics? And there's a very interesting literature that has emerged in that regard. Now, what do we know about facilitation? What can we do clinically to enhance participation and thereby enhance clinical outcomes? We have very strong evidence now that linking patients systematically to free, ubiquitous, indigenous recovery specific resources help patients sustain remission across time and reduce healthcare costs. This is why I talk about these entities as the closest thing in public health that public health has to a free lunch. We don't get this opportunity very often to utilize these free ubiquitous resources. What we can do clinically, what we've been shown is that we can do a number of things to enhance the chances that we can get patients involved and try out these resources to help them get fit for recovery. One is to broach the topic. Begin to talk about the topic of mutual-help. Have you ever tried SMART Recovery, AA, NA, LifeRing, any of these things, online? Discuss what to expect if the patient has never been. Actively prescribe participation. This is important. I'd like to you to try this out. I'd like you to go go to three meetings this week and give it a try. When you actively prescribe it, as I'll show you, you're likely to get patients, more patients into remission than if you don't, if than if you leave it up to the patient to decide. Link patients with active members whenever possible. This is another important empirically supported strategy. And then monitor attendance and patients' reactions to involvement. As I mentioned, there have been a number of different types of approaches tested to link patients to these free resources using clinical strategies. Here's one, I'm going to show you that tested in a randomized controlled trial, a linkage to AA versus providing CBT. But in this case there were different types of 12-Step Facilitation linkages involved. So in this study, Kimberly Walitzer and colleagues randomized almost 170 patients with severe alcohol use disorder to receive one of three different interventions. There was a directive intervention that where they actively prescribed, and these were all 12 session long treatments. They directed patients to attend meetings. So they said, "You know, we'd like you to go attend treating meetings this week, come back, keep a diary of your experience." This was compared to two other types of interventions. One was another type of 12-Step facilitation intervention, but this time it was left up to the patient. This was called the motivational enhancement approach. So this is leaving it to the patient in a true MI type fashion. What do you think about going? Do you think it might be helpful for you to go? Leaving it to the patient to decide. And then both of those conditions were compared to a straightforward cognitive behavioral treatment, treatment as usual for addiction relapse prevention with no special emphasis on AA. And they were compared across one year, the outcomes were compared across one year. And what they found in this study was the one that made the difference was the directive approach. So when the patients were actively prescribed participation, I'd like you to go, I'd like you to attend three meetings this week. Patients were substantially more likely to go, they were more likely to get involved and they had 10 to 20% better outcomes, clinical outcomes, throughout the course of the year, compared to patients who were, it was left up to the patient to decide whether to go to AA or whether there was no referral to AA. So very importantly, here, we can influence the likelihood that somebody goes and benefits has better outcomes by 10 to 20% by actively prescribing participation. One other thing I'll mention, there are, as I mentioned, there are dozens and dozens of studies now that have been conducted that are different flavors of these linkages. But here's one that I think is important for us to keep in mind as clinicians is the power of our clinical authority, if you will, or the power that patients place in clinical provider as being authority figures in regards to recovery and treatment. This was a study done in London, England, where they randomly assigned patients to receive one of three different referrals to NA and AA on a detox unit. So these were patients coming into treatment who were severely severe substance use disorder, addiction patients in detox. And they received either a referral from a peer, so a peer came onto the unit who was a current member of AA or NA. They had a 45 minute meeting with the patient and got them to their first meeting during and after treatment. This was compared to a doctor referral where a physician on the unit talked about NA and AA and referred them to NA and AA, recommended they go. And both of those were compared to no intervention. So just treatment as usual, which in could include some 12-Step Facilitation. What was interesting here was that overall the biggest benefit was from the peer. So when the peer with that lived experience came onto the unit, talked to the patient, they were substantially more likely to attend AA and NA during and after treatment. But, here's the interesting thing. So they did better than the doctor or the no intervention. But, look what happened when you looked at just the people who'd never been before, down the bottom here. So among those without any prior 12-Step experience, only 33% of those who got the peer intervention went to their first meeting. But, 73% of those with the doctor referral went. No one went in treatment as usual. So the magnitude of that difference, with the doctor referrals you can get compared to no intervention for people who've never been except three quarters of patients went when the doctor said, I'd like you to go. Very powerful given what we know about the benefit from participation in these free ubiquitous resources. So, very important finding that. Alright, so in terms of summary, again, most of the research that is available has been done on AA and and clinical linkages. This is what so-called 12-Step Facilitation treatments that systematically link patients to AA. When those treatments are subjected to the same scientific standards as other clinical interventions, AA and 12-Step facilitation are shown to produce as good or better outcomes at reduced healthcare costs. Clinical interventions designed to link addiction patients with these groups like AA, are found to improve outcomes by increasing ongoing community-based mutual-help participation. So this is a good match for the undulating elevated risk that is associated with stable remission and recovery. Research demonstrates now that AA in turn works by mobilizing similar therapeutic mechanisms as those mobilized by our professional interventions, but does so over the long term for free in the communities in which people live. Again, by mobilizing things like cognitive and behavioral coping skills, self-efficacy, ongoing motivation, reducing impulsivity, reducing craving, increasing spirituality, or meaning and purpose. Research on non 12-Step mutual-help organizations like SMART Recovery, like LifeRing, like Women For Sobriety is starting to emerge but is lacking. But, what the existing evidence does suggest is that other mutual-help organizations may confer similar benefit for those that select them. And again, that gym analogy, that fitness center analogy, I think is important that we need to engage patients in some kind of attractive, engaging, palatable resource that can help sustain remission across time that moves beyond our clinical realm into the communities in which people live and work. And now we have a number of empirically supported manualized interventions that are shown to stimulate successfully mutual-help participation during and following treatment and thereby improve outcomes and reduce these healthcare costs over the long term. So with that, I will say thank you for listening and I'll just mention a few things related to the Provider's Clinical Support System. There is a mentor program that is designed to offer general information to clinicians about evidence-based clinical practices in prescribing medications for opioid use disorder. And Mentors are a national network of providers with expertise in addictions, pain, evidence-based treatment, including medications for opioid use disorder. And there are three tiered approach, there's a three tiered approach that allows every mentor or mentee relationship to be unique and catered to the specific needs of the mentee. It's completely free. So you can go to it down here at the bottom and you see the link, avail yourself of that. Let people know this is a freebie, is a free service, that you can get mentoring around clinical service, adoption, and implementation. If you have a clinical question, a simple and direct way to receive an answer, you can just go to this link and post those questions there. And then also, the final thing I'll say is that the Provider's Clinical Support System is a collaborative effort led by the American Academy of Addiction Psychiatry, in partnership with all of these different organizations. So it's a large, obviously, important network of expertise and experience that you can tap into and access for your own benefit to help your patients more effectively. Thank you so much for listening to me today. I hope this has been somewhat helpful to you and I look forward to seeing you down the road. Thanks for having me.

Dr. John Kelly

substance use disorders

mutual-help organizations

recovery

remission

behavior change

coping skills

clinical facilitation

healthcare costs