Kathleen Grant MD & L. Brendan Young PhD39th Annual National Conference

Association for Medical Education & Research in Substance Abuse

November 5, 2015

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ObjectivesParticipants will be able to

Explain to patients the importance of social support in sustaining the gains made during SUD treatment

Address patients’ concerns & anxieties regarding self-help group participation

Follow up with patients & their family/friends in order to reinforce the importance of a social network supportive of sobriety

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Conflicts of InterestDr. Grant and Dr. Young have no commercial

conflicts of interest to report

Research support: Veterans Health Administration Office of

Rural Health (RH-RHRC) & Quality Enhancement Research Initiative (SUD QUERI)

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Background for Intervention

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Substance Use Disorders

Neuroreceptor-based disordersNeuroreceptor alternations may

‘heal’ w/ abstinenceChronic disorders

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Brain images of a person who has never used methamphetamine (left) and of a methamphetamine user after 1 month of abstinence (center). Lighter colors

show distribution of dopamine transporters (DAT) in the striatum. DAT distribution is reduced in striatum of methamphetamine user. Brain image of a methamphetamine user after 14 months' abstinence (right) shows substantial

recovery of DAT in striatum..

SUD Treatment ApproachIntensive SUD treatment gives patient tools to

deal with factors that increase risk for relapse:StressTriggers Exposure to substances

Continuing Care:Application of tools

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Role of Social Support in SUD Treatment

12-Step Self-Help/Mutual-Help GroupsAlcoholics AnonymousNarcotics AnonymousCocaine AnonymousCrystal Meth AnonymousDual Recovery Anonymous

Women for RecoverySMART RecoveryOvercomers in Christ

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12-Step Support Groups and SUD Treatment

Outcomes

Self-help group attendance (veterans)Reduce relapse rates & greater abstinence

@ 2 years1

Reduce subsequent SUD treatment utilization1

Lower health costs1

12-Step Support Groups and SUD Treatment Outcomes

Attendance at NA/AA associated with increased rates of opiate and alcohol abstinence @ 1-, 2-, & 5-years. Stimulants year 1 only2. (non-veterans)

12-Step Support Groups and SUD Treatment Outcomes

Frequency of NA/AA attendance was a better predictor of abstinence than attendance alone2

Weekly or greater attendance associated with improved outcome2

Less than weekly or non-attendance equally ineffective2

Why Consider an Intensive Referral Intervention to Support Groups ?

Current Practice: Give patient Support Group meeting list & encourage attendance

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Study of Intensive Referral in Veterans3

3-session intensive referral to 12-step support groups

Assessed @ 6 & 12 monthsimprove SUD outcomes Yesincrease 12-step meeting attendance & involvement Yes12-step attendance & involvement related to improved

SUD outcomes Yes12-step support group attendance & involvement

mediated SUD outcomes Yes

AA Involvement10 ingredients scored 0-10

Read literatureServiceHad sponsorBeen sponsorHad spiritual awakening/conversionConsidered self a member90 meetings/90 daysBirthdayCalled member for helpHad sponsor now

ResultsNo involvement: 26% abstinent @ 6- & 12-months> 9 ingredients: 83% abstinent @ 6- & 12-months12-step involvement mediated the association of

referral condition with improved SUD outcomesAttendance findings consistent with previous 6

month (alcohol) and 2 year studies (SUD)

Intensive Referral Intervention Session 1

Given a schedule of local & preferred NA and AA meetings

Reviewed a handout on 12-step meetingsCounselor called 12-step volunteer during session

and volunteer arranged to meet the patient before AA/NA meeting and attend together

Agreed upon meetings to be attended before next session - written into journal given to patient

Intensive Referral Intervention Session 2

If no meeting repeated AA/NA volunteer contact

Agreed on meetings to attend following week and added to journal

Discussed sponsorship

Intensive Referral Intervention Session 3

If no meeting repeated volunteer contactWrote agreement for next week’s meeting

attendanceReviewed journal

Three Key Elements

Linked to 12-step meeting volunteer

12-step journal completed

Asked about 12-step attendance

Intensive Referral in Dual Disordered Patients4

IRI compared to Standard ReferralOutcomes measured at 6 months

Greater attendance and involvement in mutual-help groups

Less drug useBetter psychiatric outcomes

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Intensive Referral Interevention Strengths

No additional costFew exclusionsBrief, feasible interventionMultiple settings: Group, Individual, Phone SessionsResidential or Outpatient SUD tx settingsCould be done by Addiction Therapists, Peer Support

Specialists, primary care, EAP, clergy settings

Intensive Referral ModifiedUrban Rural

OPT: Home each nightAttend 12-step meetings in

community where treatedAccess to AA/NA/CA/CMAIdentify sponsorSome concern anonymitySome concern stigmaAccess mass transportationFamily involved in SUD tx

Residential tx ~ 4 weeksAttend 12-step meetings in

Omaha, Lincoln, GI Some access to AALess likely identify sponsorGreater concern anonymityGreater concern stigmaNo mass transportationLack family involvement SUD tx

Intensive Referral Intervention to Improve SUD Treatment Outcomes among Rural and Highly

Rural Veterans

Funded by VA Office of Rural Health to modify IRI for rural veterans“Drug-related” meetingsAnonymityDistance & transportation

Added family involvement to intervention

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Training & Role PlayFlowsheets

Pamphlets & Journal

Support Group Resources

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Intensive Referral InterventionSession I (group/individual)Review history with 12-Step groupsBrief introduction to self-help groups (Pamphlet #1)Identify meetings they can attendExplain Self-Help JournalIdentify liaison *****Encourage patiet to introduce themselves, record name & phone # of one person at meetingEncourage patient to sign ROI for family/friendContact & educate family/friend by phone (Pamphlet #5)

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3-SESSION INTENSIVE REFERRAL INTERVENTION

Session #1Group or Individual

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STEP 3: SCHEDULING Have clients sign a Release of Information for a supportive family member/significant other/friend.

Schedule the next session and record it in Self Help Journal. Then end session with client. Following the session, contact the supportive person. If contacted, review Pamphlet #5, Self Help

Groups: Family and Friends of Veterans Seeking Recovery and mail a copy to them.

STEP 1: INTRODUCING Determine clients’ histories with 12-Step groups.

Identify clients who have and have not have attended meetings in the past. Provide and review Pamphlet #1, Self Help Groups: A Brief Introduction,

discussing the benefits and barriers to attending 12-Step meetings and to becoming a member of a 12-Step group.

STEP 2: PLANNING Give clients a list of community AA/NA/CA/CMA meetings in or near their hometown. Ask clients to identify at least one meeting they will attend before the next session.

Explain the Self Help Journal, asking clients to write down the meeting they will attend. Encourage clients to introduce themselves to at least one person at the meeting they attend. Ask clients to record in their journal the name and phone number of one member (liaison)

they meet at the meeting they attend.

Intensive Referral InterventionSession 2 (group/individual)•Verify meeting attendance •Review Pamphlet #2 on attending 12-step meeting•Identify a liaison to attend next meeting with patient*****•Call during session #2 if no previous contact with liaison•Discuss support from family/friend

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Session #2Individual

STEP 5: SCHEDULING Discuss whether client is receiving support from family, friend, or significant other..

If client did not sign ROI to supportive family member/significant other/friend in session 1 discuss with client signing an ROI at this session. Schedule the next session and record it in Self Help Journal. Then end session with client.

If session 3 is to be done by phone give pamphlets 3 & 4 to client. Then end session with client. If previously unable to reach supportive person, try phoning again. If contacted, review Pamphlet #5, Self Help Groups: Family and Friends of

Veterans Seeking Recovery and mail a copy to them.

Client did contact liaison between sessions. Client did not contact liaison between sessions.

Client did not attend meeting(s).Client did attend meeting(s).

STEP 4: DISCUSSING LACK OF CONTACT Counselor & client determine whether a liaison is available

for the meeting(s) the client will attend. If so, client tries to contact the liaison right then and arrange

to attend a specific meeting together. If not, counselor identifies a liaison or instructs client to

attend a meeting and identify a liaison.

STEP 4: DISCUSSING CONTACT Ensure liaison contact information is recorded in Self Help Journal and in client’s

phone. Discuss whether client is seeking or finding a

potential sponsor.

STEP 2: DISCUSSING NON-ATTENDANCE Discuss reasons for not attending meetings

Review Pamphlet #1 and emphasize attendance. Identify meeting(s) to attend before next session.

STEP 2: DISCUSSING ATTENDANCE Congratulate client on meeting attendance.

Using Self Help Journal, discuss the meeting(s). Identify meeting(s) to attend before next session.

STEP 3: CHECKING LIAISON CONTACT Provide and review Pamphlet #2, Self Help Groups: Going to 12-Step Meetings.

Ask if the client identified a 12-Step member liaison and contacted that liaison since the last session.

STEP 1: CHECKING ATTENDANCE Ask if the client attended one or more meetings since the last session.

Intensive Referral InterventionSession 3 (group/individual/phone)•Verify meeting attendance•Review barriers to meeting attendance (Pamphlet #3)

and participation (Pamphlet #4)•Determine if contact made with liaison & can contact during session•Discuss support from family/friend

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Session #3Group, Individual,

or Phone

Address client(s) who did attend.

Address client(s) who did contact a liaison. Address client(s) who did not contact a liaison.

STEP 1: CHECKING ATTENDANCE Ask if client(s) attended one or more meetings since the last session.

STEP 2: DISCUSSING ATTENDANCE Congratulate client(s) on meeting attendance. Using Self Help Journal, discuss the meeting(s). Identify regular meeting(s) to attend in future.

STEP 2: DISCUSSING LACK OF ATTENDANCE Discuss reasons for not attending meetings

Mention higher relapse rate among non-attenders. Identify regular meeting(s) to attend in future.

Address client(s) who did not attend meeting(s).

STEP 3: CHECKING LIAISON CONTACT Provide and review Pamphlet #3, Self Help Groups: Problems and Solutions.

Provide and review Pamphlet #4, Self Help Groups: Participation. Ask if the client identified a 12-Step member liaison and contacted that liaison since the last session.

STEP 4: DISCUSSING CONTACT Ensure liaison contact information is

recorded in Self Help Journal and in client’s phone.

Discuss whether client is seeking or finding a potential sponsor.

STEP 4: DISCUSSING LACK OF CONTACT Counselor & client determine whether a liaison is available for the

meeting(s) the client will attend. If so, client tries to contact the liaison right then and arrange to attend a

specific meeting together. If not, counselor identifies a liaison or instructs client to attend a

meeting and identify a liaison.

STEP 5: DISCUSSING SUPPORT Discuss whether client(s) is/are receiving support from family, friend, or significant other, and end session.

If previously unable to reach supportive person, try phoning again. If contacted, review Pamphlet #5, Self Help Groups: Family and Friends of Veterans Seeking Recovery and mail a copy to them.

Questions?

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References1“Encouraging Posttreatment Self-Help Group

Involvement to Reduce Demand for Continuing Care Services: Two-year Clinical and Utilization Outcomes,” Humphreys & Moos, Alcoholism: Clinical and Experimental Research, 31 (1), 64-68, 2007.

2“Attendance at Narcotics Anonymous and Alcoholics Anonymous meetings, frequency of attendance and substance use outcomes after residential treatment for drug dependence: a 5-year follow-up study,” Gossop, Steward & Marsden, Addiction, 103, 119-125, 2007.

3“A randomized controlled trial of intensive referral to 12-step self-help groups: One-year outcomes,” Timko and DeBenedetti, Drug and Alcohol Dependence, 90, 270-279, 2007.

4“Intensive referral to 12-step dual-focused mutual-help groups,” Timko, Sutkowi, Cronkite, Makin-Byrd, Moos, Drug and Alcohol Dependence, 118, 194-201, 2011.

Thank YouDepartment of Veterans Affairs

Office of Rural Health Veterans Rural Health Resource Center

Iowa City VA&

Substance Use Disorders Quality Enhancement Research Initiative

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