Well, hello, and welcome to this lecture on mutual help groups for addiction. My name is Keith Humphreys. I'm a professor at Stanford University, a professor of psychiatry, and I've worked in the addiction medicine field for about 35 years. When I first started my career, I was surprised to find out that there was a significant presence of people in our field who were not professionals, and I'd never heard of groups like Alcoholics Anonymous and Narcotics Anonymous. When I did hear of them, I don't mind saying my initial reaction was skeptical. I didn't understand how we could help people with a serious disorder without people who had MDs or nursing degrees or were psychologists or social workers or had some kind of advanced training, as well as, I don't see how we can help them if we didn't have any particular technology or medicines or so on. So I was skeptical of them, and if you're skeptical of them, I don't blame you, because that's exactly where I started when I first heard of them, and that was not unusual actually at the time. Many people were skeptical of them. But I've been on a journey, as the field has over the last 35 years, of doing research on them, but also reading my college research on them, and it really overcame my initial skepticism, which is a good thing for science to do, to teach us things we don't know. And I have come to see them as a very important ally in the quest we all share to help people who are experiencing addictions, help them, and also help their families. And I'm going to walk you through the journey that I went through myself. As mentioned, my name is Keith Humphreys. I'm a professor of psychiatry at Stanford University. I'm also in the VA Palo Alto Healthcare System, where I'm a scientist doing healthcare services research on mental health and addiction. I'm speaking for myself today, not speaking for my employers, of course. And I don't know that there are any commercial interests in the domain of mutual help, but if there are, I don't have any. So what are we going to try to get done today? We're going to start by appraising the research base behind 12-step interventions. Now, 12-step is just one kind of mutual help group, and the reason I'm focusing on it is absolutely not because it is the only or should be the only type available. I'm doing that because that's where most of the evidence is, and so we're going to be focusing tightly on the evidence. In addition to learning about the groups themselves, I'll also be talking about practical strategies for facilitating introduction to 12-step groups, and there are some very nice empirically validated protocols that you can use in your practice, whatever your practice may be, primary care or specialty care or inpatient or outpatient or so on. And those are things we can do, even though in the end, we don't control these groups, of course. They run on their own, but we can help people find them. So we can sort of do a warm handoff and be part of that journey. And then the third thing we will learn about today are what are the implications of these for our healthcare system? For example, about cost, and I'll show you some evidence that I think is interesting in terms of seeing how, if you're in the situation many of us are in, which is often being asked to take care of more and more people with fewer and fewer resources, this is a way we can extend those resources at a fiscally sustainable way. So first thing to say is that addiction mutual help groups are an international phenomenon. We certainly see them in the U.S., but we see them all over the world. And that may tell us something about the condition of addiction, that no matter where you go, it seems that people who experience this find some healing in each other's company, perhaps something about the shared experience, building empathy, perhaps also about the reduced shame of you don't feel bad for being addicted because everyone else in the room is as well. But in any case, we see this over and over. So it's sort of, you know, conceptually interesting to understand the disorder and also to show some optimism that people who have a problem can in fact be part of the solution to that very problem. The types of groups vary enormously. Here are just some examples you might see in different countries. In Austria, there's a start of groups called the Blue Cross, which were mutual help groups that affiliated with Catholic churches. France had the Libre, which means to live free. And it was actually came out of the socialist workers movement. It was off the labor movement, but it was to help workers who had alcohol problems. And they combined the solidarity, labor issues with solidarity around recovery. Hong Kong had SARDA, which is a alumni group for people who have been treated in the health care system for typically heroin addiction and then continue to support each other to try to translate those gains to the rest of their life. Danshukai is in Japan. It's one of multiple Japanese mutual help groups that is in some ways influenced by Alcoholics Anonymous, but also very much its own thing. One of the things about Danshukai that would be different than in any meeting is people come as married couples primarily rather than as individuals. And the person who has got the alcohol problem usually, but not always, the male attends with the person they're married to and they both talk about their experience. Poland, at least before the Berlin law fell, had abstainers clubs. So it was hard in totalitarian Eastern Europe to host AA meetings because the government is inherently going to be suspicious of an anonymous society of people who are meeting privately. And so they had to adapt to that. So they figured, we'll just give up on anonymity so no one will think we're plotting to overthrow the government. And it's entirely public. And they even had a television show where people come on and say, hi, I'm in the abstainers club. And they would support each other in their recovery. But without any effort to hide the personal identity, as is hidden in an anonymous fellowship, as obviously the name indicates. Sweden has the Links. The Links is another group influenced by AA. It's very much its own thing. It's interesting. Sweden is an extremely secular society. And one of the interesting studies that has been done of the Links asked people who are participating in this group, which uses steps that have spirituality and so on. But when asked the question, I know there is a God and I have no doubts about that. Something like 90 percent of their members said, no, I don't believe that at all. So they're more spiritually grounded than Links. But nonetheless, Links is still popular and successful. Swedish, Swedishization, if that's a word. And then I put narcotics and arms in Iran. Narcotics and arms is, of course, in, you know, over 150 countries. But the reason I picked Iran is it was why they believed early in that the 12 step fellowship, because they do have a sort of Western Christian provenance to them, would never spread into an Islamic country. And that held true for a long time. But it isn't true anymore. Iran has actually quite robust narcotics and arms membership, and it is perhaps maybe even one in every five NA members on Earth lives in Iran. And they just managed to reinterpret. And as we'll talk about, you know, the spiritual and philosophical views of these groups are intentionally flexible. And they found ways to interpret it that made it consistent in their mind with Islamic society in the way it had been reinterpreted many times within Western societies with a more Christian heritage. If you're interested in this, I did write a book a long time ago now that you can probably find very cheap on book sites, but that goes through lots of different countries and lots of different examples of this phenomenon that no matter where you go, you find these different types of fellowships. Now, that's where, you know, that list of all of the many options among. But, you know, most of the research has been done, outcome research particularly has been done on alcoholics. We are getting more. We've had a lot more in the last 20 years focused on 12 state groups focused on drug addiction. So those would be groups like cocaine, anonymous, narcotics, anonymous, obviously methamphetamines, and we have a very small amount of which we had more, but we do have some on non-12 step groups and like smart recovery is an example of that or lifering recovery. Let's talk about let's talk about A.A. A.A. is the we are a nation with many, many mutual help organizations for all kinds of problems and probably at least one in six, maybe one in five Americans at least once in their life has been to a self-help meeting for something, some condition or order or life crisis or transition in life. And A.A. is the biggest of all those. And it's surely also the most influential, both in influencing other 12 step groups, but also influencing the founding of other organizations such as I talked about just Minico. It was founded in the Midwestern United States, it happens it was founded in Akron, Ohio. As it turns out, the the history archive of the psychology and I'm a psychologist is in Akron. I gave a lecture there, a history lecture, and I got to go see some of the heritage there, which is worth doing, including the house of one of the founders is still standing. If you if you want to go see it, the two people founded it who are in the program lore called Bill W. And Dr. Bob, we know the real names now, but that's what they describe themselves within the program, met when Bill Wilson was on a business trip, was afraid he was going to relapse. He had been struggling for a long time and he was linked by a local. Woman, Henrietta Seiberling to. Robert, Dr. Robert Smith, who was also had struggled with alcohol for a long time. And what they found is that when they met together, they had a relief from need to drink, that they were not used to experiencing something special and magical happened. And they held on to that insight ever since that two alcoholics, as they call themselves, could could provide the seed of sobriety in a way that maybe no one else could have could have done for them. And this fellowship, they decided its sole purpose would be to help alcoholics become sober. Now, I have alcoholics and quote, because we don't really use that term alcoholic, you know, at least typically we wouldn't call a patient alcoholic or diagnose someone as alcoholic. It's not a diagnostic code because, you know, many people view it as stigmatizing code. But that is what the people in AA call themselves. And I think people should be allowed to call themselves whatever they want to call themselves. So I put that in quotes to say that's what members say. And they even say that repeatedly in meetings, like when they speak up, they'll say, you know, my name is Joe and I am alcoholic. The second thing is that the word sober has a special meaning, a bit different than it is commonly used. Normally, when we say someone's in sobriety or sober, we mean they're not drinking and that is certainly what AA means in part, but they mean more than that. There are 12 steps in AA, only one of which actually refers to alcohol. The other 11 refer to a different way of living, spiritual transformation, honesty, compassion, relationships, caring for others, admitting one's errors, trying to atone for mistakes. It's an entire way of being, really saw this as central to maintaining your sobriety. You had to do all that, not just sort of grit your teeth and stop your alcohol consumption, but actually change all these other things. And that state is what they mean by sobriety versus just dry. It's no alcohol consumption plus this enriched life, the emotional growth, the spiritual growth, the healing of relationships. AA offers people different sorts of resources. There are meetings, obviously, where people gather. There are different sorts of meetings. Some meetings are speakers meetings where someone will come up in the front and speak at some significant length about what happened to them, what things were like, what happened and what they're like now. And it has a narrative structure of, you know, sort of like typically like, you know, fall getting worse and worse and worse and then getting into Alcoholics Anonymous and getting better and better. They have first step meetings and sort of by tradition, if there's a newcomer will be a first step in which is talking about that step, which deals with being powerless over alcohol. There's also plenty of meetings that have to do a topic of the day or start with a reading each day and react to the reading. Some do meditation or some type of prayer at the beginning and so on. There's almost as many types of meetings as there are people in the world. They have a tradition of sponsorship. Sponsorship means an experienced member will support a less experienced member in the journey of recovery. And there are some things to keep in mind here we'll get into later about, you know, helping people pick if you're treating somebody who's looking for a sponsor, making sure they pick a sponsor is good for them. And there's quite a bit of literature in AA. The most famous one is called The Big Book, which is Alcoholics Anonymous, and it was big because they printed it, didn't have any money when they were doing this in the 30s. So they printed on cheap, pulpy paper. So it's pretty, pretty, was pretty large. But people still call it The Big Book, which has lots of stories in it. There's other books that have related to 12 steps, 12 traditions. There's books that give various sorts of advice for living and so on. And many people find these sorts of things helpful in their recovery journey. I have another word in quotes here, a disease model. Talk about alcoholism as a disease, but they would mean it differently than, say, a oncologist would talk about cancer as a disease. It didn't mean a strictly biomedical phenomena. In fact, they were so concerned that people might misunderstand them, they almost used the word malady instead of disease. But, you know, someone pointed out that malady is a very quaint, archaic word that hardly anybody in their 30s was saying anymore. People wouldn't know what they meant. So they kept with disease. And but they meant more than the physical. They meant a spiritual disease, emotional disease of life and living for the cure for which that's what sobriety, that's why sobriety involved more than just the stopping of alcohol. It's one of the, independent of what you think about alcoholics known as an intervention, just as an organization, it is spectacularly successful. So you have two people in 1935, by 1950, there are 50,000 people. Now, I did some work estimate this at one point that probably worldwide, there's at least five million people in alcoholics in more than 180 countries. That is pretty spectacular success. It is, like I said, the biggest, most successful mutual help organization in America and probably the world. These are the the 12 steps and you will have all heard of these, you know, they are, you know, like, you know, there's you could say it's steps to change or a theory of change. There's personal aspects and there's interpersonal aspects, you know, so there's both being, for example, honest with oneself, but also admitting to other people about the things we've discovered about ourselves. Excuse me. One of the things that a lot of people don't know, even members, is that the 12 steps are not mandatory. It even says in one of the original texts. That these steps are but suggestion. So people don't have to have to do them, they usually do, but there are many people who participate and they say they enjoy the fellowship and the support and don't actually work the steps, as it said. As I mentioned, the first step there, we admitted we were paralyzed over alcohol, that our lives have become unmanageable. That is the only step that mentions alcohol. The rest of it is about this broader healing process. The 12 steps have been adopted by many other organizations, often making changes to make it fit. But this basic concept still exists. Worth mentioning, too, the 12th step is worth some attention. Having had a spiritual waking as a result of these steps, we tried to carry the message to alcoholics and to practice these principles in all our affairs. That is the thought that you have to give it away to keep it. It also helps the organization grow and helps to make it work. It also helps the organization grow and helps sustain the institution of sponsorship. So. we have learned this is a very popular organization. It doesn't necessarily mean that it's a. I'm going to tell you a story. My grandmother, like many people in her generation, used to take a pill called Carter's Little Liver Pills. They were very popular. Millions of people took them. And then eventually, the Food and Drug Administration took a look at these pills and found out they were inert. There was nothing in them. They were just a pure placebo. And they certainly had nothing to do with the human liver. And so, they said, the company, you can't call them Carter's Little Liver Pills. So, they took liver off the label, and they sold them as Carter's Little Pills. And people still took them. They were very popular, but they didn't make any difference. So, the fact that AA is extremely popular and has spread, with no disrespect to those, anyone who might be in AA, doesn't mean we shouldn't evaluate whether or not it works. Because there's plenty of things. Look at diets, you know, that can be very popular or, you know, and it's our job to check. So, I want to look into that now and show you the work many, many scientists have done. I've done some of this, but I'm a small part of the amount of evaluation that has been done on these organizations. So, this was, actually, I'm sorry, just go back for a second, just give you some context. There had been studies for a long time, at least since the 70s and probably in the 60s, showing simple correlations. So, these would be studies where somebody, a researcher, would come in to an AA meeting and say, you know, can I come in? And, you know, if they let him in, say, you know, I'm going to give you a survey and ask how you're doing. And then they would conclude something like, you know, the people at the meeting who had been going the longest were doing the best. And there's a lot of ways to explain why that could be true. It could be true that AA, the longer you go, the more you benefit. But, you know, these studies didn't have a control group. Maybe other people who had spent just as much time working on it in other ways would have done as well. Maybe all the people who did, you know, the AA was bad for dropped out or the scientists showed up. It was just a cross-sectional study, it was just correlational. So, we had that kind of stuff, but it was easy to look at that and be still pretty skeptical because it wasn't very strong in terms of validity. So, this was a study that kind of blew a lot of people out of the water because it's the first time really somebody got a good randomized evaluation of AA. And this let us, you know, not worry so much about the kind of selection and dropout problems and comparison problems we had in all those correlational studies. This was done, I'm proud to say, by my colleague and friend, Dr. Chris Timko, who's at the Palo Alto VA in Stanford Medical School, like I am. She did this at our hospital. And she had 345 outpatients at the VA who were already in substance use care. And she was trying to figure out, how do I get some type of randomizations? What she realized was, well, she can't randomize to AA or NA or CA itself, but she could create an intervention to facilitate their participation and randomize to that. So, that's what they did. So, about half the people were randomized to get sort of the, probably the standard AA introduction or NA introduction, which is, there's these groups, you may want to attend, here's a pamphlet if you want to go. But the other one was much more of a warm handoff, where somebody sat down with them and said, you know, there's these groups, here's what they are. Let's talk a little about your feelings about it or anxieties you have about it. And different, you know, anything you're worried about, or if, you know, do you have to speak or not? And how would you get there? And, you know, is it near a bus line or that kind of thing? And also, an offer to say, if you like, I can connect you to somebody who's already a member, and they can take you to your first meeting. So, it was a pretty short intervention, but it was a lot more warm and informative and relieved any worries, more than just a simple, you know, there's groups out there, if you want to go, you go. So, she got a very good follow-up rate of this population, over 80%, which is hard to do. And first off, she showed this more intensive referral did, in fact, work in the sense that people had higher rates of being involved in 12-step groups. But the second thing is really dramatic differences at six months, and then later in her follow-up study, shown at 12 months, in their problems. These were problems as measured by the addiction severity index, and the alcohol and drug scales were dramatically better. Now, that is pretty remarkable, given that the only thing that the treatment group got was this sort of, you know, little more detailed warm handoff into these groups. So, we can conclude two things from this. First, how you refer, what you do as a clinician really matters. Second, this is very consistent with these groups being genuinely effective, because people are being randomized to encouragement, and then they go, and they go at much higher rates, and their outcomes are dramatically better. Who would not want 60% greater change in their patients, just from this little step of referring to the group? So, that is much stronger than a simple correlational study, or a study with no comparison group. And this was very important for establishing, as a credible scientific statement, that these groups were effective. But it wasn't just that study. Now, we have now other demonstrations, again, randomized demonstration. So, this was a study first authored by Dr. Mark Litt, and his colleagues out in Connecticut, and they were doing something called network therapy for addiction, specifically alcohol problems. And this is a strategy where you try to link people to as many sort of abstinent promoting settings and people as you can. And that, of course, that could be alcoholics, but it could be lots of things. It could be an athletic league, or a parent's club, or a religious or civic association where drinking does not occur. And in a randomized study with 210 patients, half of them getting case management, half of them getting this network support, then they found that if you were randomized, again, not chosen, randomized network support, you had higher AA involvement and about 20% more days of abstinence. That, again, suggesting a positive benefit. So, we have those initial trials that are pretty important, and I had seen these done and was impressed with them, and began to think about something else seemed to be important, which is these groups don't cost any money. They don't have any professionals, you know, running the groups or managing the groups. People do throw in a buck or two into the basket, you know, to pay for the, maybe the civic center for the room and stuff like that, and make their own coffee. They're really, really inexpensive. What are the cost implications for a healthcare system that we have these very large informal network of people rallied around a particular health problem? So, I decided to look at that with my mentor, Rudy Moose, the person who brought me out to California in 1993, and we did it in the Veterans Health Administration. This was a quasi-experimental study, and it was a follow-up of over 1,700 veteran patients. They were very racially diverse. They were not, unfortunately, diverse, though, in terms of male, female. They're 100% male. So, there's a limitation on generalizability, and the way the study was done is 21 to 28-day programs run by the VA around the country. We had them profile by looking at their materials and actually sending an anthropologist out to them to see about the content of their care, and we picked five programs that were very, very 12-steppy, if that's a word. Lots of use of 12-step principles, maybe some 12-step members on the staff, huge emphasis on getting people into the groups, and then five programs that were very good programs, but just absolutely not doing the 12-step stuff. They were cognitive behavioral programs. Cognitive behavioral therapy is what I was trained in. It works very well, certainly a credible thing to do, but just the point here is that they were different, and they're not so much focused on 12-step kinds of stuff. Now, this is not a randomized trial, but it's pretty close to randomization because the closest programs were hundreds and hundreds of miles apart. So, largely, what's going to happen is, you know, I'm a veteran. I'm going to go to the nearest facility rather than drive 500 miles because I really have a strong feeling about cognitive behavioral therapy. I really have a strong feeling about 12-step therapy. That doesn't seem very likely. So, we do have some basis for inference here that the treatment, you know, differences that we see would be due to the treatment, and we actually extended the basis for inference further because one of the wonderful things about the VA is you can look at everybody's healthcare utilization going back historically. So, we picked out people who had the same in terms of, you know, financially, total cost, the same mental health and substance use care histories of utilization in the VA. So, that's equal between the two groups, which is important because we're going to try to make, in the end, inference about the way these different types of models affected people's future healthcare. Now, we looked, are they different on other things that might be agnostic and would then kind of ruin our study for self-selection? Couldn't find any. You know, they were very similar on, you know, social stability, marriage, employment, whether they had a comorbid psychiatric disorder or what their severity and type of substance use was, their history of self-help group involvement, very similar. So, a year later, we first off got very good follow-ups when we actually got back in touch about 84% to assess their clinical outcomes, and to assess their utilization outcomes, well, we got 100% there because, again, in the VA, you can see everything anyone is using, even if they move across the country and go to a VA somewhere else. So, first off, we wanted to see, you know, did it matter that you went to a really 12-step, 21- to 28-day residential program? It really did matter. So, a year after discharge, if you'd gone to one of those programs, you were much more likely, for example, to have a sponsor. You were more likely to go to groups. If you did go to groups, you went to more groups. It's not that people who went through cognitive therapy never went at all, but it just wasn't anyone you knew as much. So, the content of treatment did seem to produce that effect, which means we had a nice basis for potential influence here. So, first, let's look at clinical outcomes. In the slide that you can see there, the orange bar is the 12-step condition, and the teal bar is the cognitive behavioral condition. So, to start with abstinence. So, this was a tough abstinence measure. It was 100% abstinence from everything for the entire year. Note, not one drink, not one use of any drug. And you can see there that it's significantly higher than the 12-step condition. The other two measures were not significantly different. You can see a little difference, but it didn't reach, you know, P less than 001, which is what we used. Those measures were substance abuse problems, we asked. So, these would be things like my substance abuse problems with marriage, my job, neighborhood, lease, whatever. And the people, there was a proportion of people who said no, no problems at all or anywhere. Pretty, pretty similar. And then positive mental health in an absence of any serious psychotic or any other serious psychiatric symptoms. And again, both groups doing about the same on that. So, clinical outcomes the same except for abstinence, which was better than the 12-step condition. But the main thing we're looking at here is cost and utilization. And here we did see a big difference. So, again, same color scheme, orange is 12-step, and the teal is cognitive behavioral. Cost difference is pretty pronounced. This is in the year after care, after the index episode, about 40% less. And that came about both by fewer inpatient days for substance use and mental health and fewer outpatient visits for substance use and mental health. Now, it's important to think about this and the clinical outcomes together. Normally, we would think, well, you got less healthcare, so your health is going to be worse off, right, because you're not getting taken care of the way you need to be. But if you think here, we go back to this last slide, we can see that's not true. People who went to the 12-step groups are doing as well or in abstinence better than the groups who went to cognitive behavioral treatment. So, how do you explain this? Less healthcare and as good or better health? So, I wish, I really wish I knew this was going to happen at the beginning of the study because I might have tried to measure it. We didn't kind of measure what was the mechanism, so all we can do is speculate. But I can tell you what my speculation is. If you go into any, say, primary care doctor's office in the United States, you will see people in the waiting room who are really sick and need to see a doctor. You also see people who are lonely, people who just need to talk to someone, need to know that someone in the world knows they're alive, needs a hand on their shoulder, needs some encouragement. They're there maybe because they're bored and they just want somewhere to go. Now, all those things are perfectly normal human needs and experiences. Everyone has them. I have them. You have them. But you don't need an MD or an RN or a PhD to fulfill those needs. So, possibly what is going on is when people go get involved in a 12-step fellowship community, they start getting those needs met there. So, now when I need just to know someone cares about me or I just need somewhere to show up so I'm not sitting home alone all day, I need some encouragement. I get it there. And so, I go to the official healthcare system less, but my health is just as good. And that could help explain that. Now, if that's what's going on, it's certainly very, very good because it means we're making healthcare a lot more efficient. I mean, we don't have enough mental health and substance use care in the United States would be very good if the only people who got it are the people who really, really need it, and that seems to be going on here. Now, I later extended this study out to two years, and I thought it would be not unusual for the effects to fade away, you know, regression to the mean is a real thing. You can also imagine people would start to relapse, and maybe they would start to look more similar. Turned out the opposite happened. The two groups got further apart. So, the difference in how involved in 12-step they are, the two years was higher than it was at one year. The difference in complete perfect abstinence over the last year got bigger. 12-step groups now doing, you know, over 10 percentage points better. And there was a further $4,700 healthcare cost reduction. So, over those two years, people had $13,700 less per person in mental health and substance care, and again, wow, attaining better health. So, pretty impressive finding. You know, VA treats over 100,000 substance use disorder patients a year easily. You multiply those together, and you realize it's a pretty spectacular lift to the healthcare system that these groups bring. I mean, they're saving, you know, VA billions, but of course, the VA is only a small part of the entire healthcare system. So, they're taking quite a bit of burden off them. We should be grateful that they're there, not just in the public health sense, but for that matter, as taxpayers. Now, as more and more in this work started to accrue with a lot of support from VA and a lot of support from NIAAA, I thought it would be useful to try to pull all the trials together. And I did this using a technique from economics called instrumental variables analysis, which I'm not going to explain because it's incredibly complicated, but what it does is it lets you get an estimate of what the effect of an intervention is without selection bias. Selection bias, meaning the fact that the people who go to the intervention might be different than the people who don't, and that could affect the outcome data you get. So, we did that by taking these six clinical trials, and I'm grateful to all the scientists who donated that data to us because we had not run any of these trials ourselves. And using the randomization in these trials, we were able to estimate the impact of AA apart from any selection bias, did it still have an effect? And in five of the six trials it did, we again seemed to show that it really isn't, you know, something like, oh, just motivated patients go or people with less serious problems go or people who are really, you know, able to stick with things go. AA really does have a causal effect benefiting the course of drinking problems. We tried to replicate this years later with support from NIDA because NIDA had supported a lot of trials. And these would be trials that, you know, tried to encourage people to join groups like Cocaine Anonymous, Narcotics Anonymous, Methamphetamine Anonymous. I'm grateful to all these people there who donated their data to be part of this collaborative. And what it showed is that the effects were not as strong, in part because in the AA studies, the intervention that designed to promote involvement in AA were really successful. And in the drug studies, it was far less so. So the people who got the encouragement went a bit more, but nowhere near as much. So that made the instrumental variable analysis a bit weaker than we would have liked. We were able, though, to run, you know, more traditional regression analyses, which are vulnerable to selection bias, I have to say. But nonetheless, were encouraging in showing, you know, drops in the ASI drug composite and also in alcohol composite. Quite a few of these patients had co-occurring alcohol problems. So still some risk of bias there with that type of analysis. I would say the data isn't quite as strong as it was for AA, but it's certainly very encouraging. It's also worth noting there was no difference in any racial group or between men and women in their likelihood of participating in groups. Since these groups were originally founded almost entirely by white men, the fact that they now appeal equally across diverse groups is certainly good news. So more recently, working with John Kelly at Harvard University and Marita Perry at the European Minoring Center for Drugs and Drugs Addiction, we decided to take all the best studies that have been done to do what's called a Cochrane review. Now if you haven't done one of these, they're one of the hardest things to do in medicine It literally takes a year just to get your strategy for how you're going to review the literature approved. There's so much intense comment to see whether or not you're looking at the right studies. But we went through that and we had seven or eight levels of review on this. And I have to give John Kelly great credit because he did a lion's share of the work of pulling all this data together. You know, these slides are publicly available. So the Cochrane review is a free and in the public domain you can look. But we did search very intensively for rigorous studies of alcoholics and non-drug users in every country. We could find in multiple languages, in many different databases, done from many different disciplines. In the end, we identified 27 primary studies that enrolled over 10,000 people. Mostly they were clinical trials or randomized clinical or close to quasi-randomized trials. We also looked at some economic studies to look more at this healthcare cost. Everyone had to report follow-up results and they had to have multiple groups and reliable measures, all of which were pretty good. These are the outcomes we set out to look at. We certainly want to look at abstinence because, you know, that is one of the goals of AA obviously. We also looked at other things, more things you might think of as harm reduction outcomes, so reducing the consequences of drinking when it occurred, reducing the number of drinks per drinking day, days when people drank, as well as, you know, the healthcare effects that I mentioned earlier. So this is probably the most startling slide, so I'll just put it in there. You know, one of the things we looked at, what about complete abstinence? So absolutely not one single day of drinking at all. And this slide compares it in various trials to very good, tough competitors, motivational enhancement therapy, cognitive behavioral therapy, which are really good treatments. And the blue bar is what showed up in the 12-step facilitation counseling studies where you introduce AA during treatment, you explain what it is, and you really encourage involvement and people, you know, do in fact go more, just as I've shown you in these previous studies, for example, by Timco. Motivational cognitive therapy, I assume you all know what those are, they're certainly very good ways to approach people with drinking problems. But these effects are very large. If you were shooting for the outcome of complete abstinence, you would definitely go for the blue bar. I mean, sometimes you're talking, you know, half again is good, almost twice as good. You know, if this were a cancer study, you'd be furious if your doctor gave you anything other than the blue bar. So there is a large genuine effect here on abstinence. But it wasn't just abstinence. So despite the fact that that is the thing it emphasizes, when we started looking at outcomes like, let's say people still drink, how often do they drink or how often do they drink heavily or how many drinks do they drink on drinking days, the 12-step interventions actually came out as good, in some cases, even slightly better than cognitive behavioral and motivational enhancement therapy. So it's sort of interesting, it sort of packages abstinence all in, but on the ground, there are lots of people who use it to cut their drinking down, but they still actually still continue doing some drinking. So that's, but it shows it's, you know, it's not a one trick pony. It also shows that a long time ago, there was an idea that there was something called an abstinence violation effect, that if you emphasized abstinence, then that meant if anybody relapsed, the relapses would be worse. No evidence of that. In fact, more likely opposite, the people continued drinking were, if they drank about the same amount or sometimes even less than people who had interventions that didn't set abstinence as the only goal. We replicated as well the cost findings. So other researchers also found that if you got involved in these groups, your healthcare costs went down. And then we also looked a bit at other types of outcome that have been found here. I'm sorry, actually jumping here. There's some other outcomes that have been found in the literature, not all of these from the Cochrane Review, but number of studies you see reduced depression, less anxiety. So that's, you know, better mental health, greater sense of, you know, feeling life is meaningful and stronger intimate relationships, like people saying they're happier in their marriage, for example, they have more friends. So that is the evidence that, yes, this does seem to work. Now we're going to move to the mediation question, which is how does it work? So if you have, you know, A leads to B leads to C, oftentimes how we report things is A leads to C, like, you know, treatment produces this outcome, but like what happens in treatment? Why does the medication work? Or why does going to this 21 day program, why is attending AA actually work? What is the causal chain? And from A to B to C, B is called the mediator. And there's people have been trying to figure out what are the mediators of 12 step effects. This is a, was a structural equation model, used to have lots of statistics and beta weights and gamma. And when I would put that up, everybody would lapse into a coma. So I've kind of taken all that out, but it's all in the reference there. If you're a statistician, you want to read it, it's an analyst of behavioral medicine. But this is our big mediation study we did with several thousand people assessed at baseline one year and two year. And we're trying to explain, you know, we see people going to more and more 12 step groups. And at the end of the study, they're using substances less. What are the things that changed at the one year in between? And we found four things. One was active coping. So that was using, when presented with some kind of stress, using strategies like saying, I made a plan. I found some information. I thought about different courses of action versus, you know, avoiding coping. Like, you know, I pounded my fist on the table. I pretended the problem didn't exist. People became better copers, not just with substance use, with everything, better copers with stress. Motivation to change increased. So more a sense of, I want to do this. Something that is said wrongly and unfairly about 12 step groups is only motivated people to cope. That's actually backwards. People who go become more motivated. And why wouldn't they? You know, it's like, you know, they're around other people who are trying to do this. You know, there's some connections. Sometimes there's some laughter, some fun. You want to be a part of it. And so it actually increases motivation. We saw two changes to friendship networks. One was sort of general friendship quality. So if you ask people questions like, do I have people I can trust, I can count on? They were more likely to say, yeah. But also if you went more specifically and say, do you have friends who specifically support you in your effort not to use? They were more likely to say yes. So those things changing seem to help in the long term, keep substance use out of the person's life. And we did look at this also just specifically on this friendship question, like who were these friends? And it was, there was quite a split in the study. So we asked them to enumerate when you're, who you're hanging around with, who people are close to. And about half the sample had 90% of their friends, they said there are other people in 12 step. And the other sample had anyone. The red being so low relative to the orange on your left is, and it turned out those people really hanging around a lot of 12 step friends ended up more likely to be absent in the long term. Now, like, you know, none of this should surprise us really. I mean, if I told you I really wanted to start jogging and I joined a jogging group and I made some friends and they were on the same journey with me and it helped me stick with it. You would say, well, that makes sense. Or if I joined people, we're all trying to, you know, a diet and we all work together. You would think, well, that makes a lot of sense. I mean, health behavior change often has a social component. So we shouldn't be surprised that going into an organization that there's lots of the people on that journey who are there to support me, give me practical tips and also inspiration hope because they're further down the road than me. And I can see maybe I can get to a better place than I am now that that works. So you can really understand. I think if you, if you just weren't an alcohol or addiction person at all, and you were just looking at us in terms of health behavior change in general, like a lot of this, I think what I've said, even though it was specific to addiction would resonate with you. What does that mean? So why does this matter? So first off, we ought to respect 12 step neutral health group. It's easy when you're trained highly, as all of us are. We should feel good about it. It's a lot of work, but you can end up perhaps looking down on people, even though we shouldn't who don't have so much training, like they can't possibly know that much or they can't possibly make the contribution. We should not have that disrespectful attitude, which was the one, as I mentioned, I started with 35 years ago. These groups do help people. They genuinely help a lot of people. And they are our partners in this important endeavor of reducing the terrible morbidity and mortality that we see from addiction. So we should be grateful there and see them as valued partners, not as lesser than us just because they don't have as many letters after their name. We should refer patients to groups. You know, it is many people find their way directly through, but a lot of people find their way through a healthcare provider. And you know what this, you know, the research that I've talked through shows is that, you know, how we refer makes a lot of difference. So if we actually actively support it, particularly if we can tell someone a little about what our groups are like, or are you have any fears about it you want to talk through with me first, or if you're in that position to be able to say, would you like to meet somebody who's a member before you go and maybe take you to the first meeting, that kinds of stuff. If we can do that, we can help them and also extend our impact much longer. And who doesn't want to do that? You don't get that much time with your patients in American healthcare. You know, the odds that you can stick with somebody for, you know, one, two, three, four, five years are pretty low, but these groups can. And if you are the person who helped get them involved, then in a sense, you are still staying with them for those years. And so we help to make space for mutual help groups. And I mean that both in a literal sense, but also in the sense of like, you know, if you have an organization, if you're on the board of the civic center or your house of worship or your hospital, and you let them have the physical space to meet, I think that's a great thing to do to support them. But also favorably just in our heads and in our thinking of that not everything has to be done by treatment professionals. There are other resources out there for individuals, but also for the country. Now there's some things also I very much don't want to imply. Some people, for reasons I've never fully understood, when I present evidence showing that 12-step groups work, they say, oh, what you're saying is every single person who has an addiction absolutely must go to a 12-step group where there's something wrong. Absolutely positively do not mean that. If I told you that there's evidence that SSRIs reduce depression, that would not mean no one could possibly ever get better from depression without an SSRI or that everyone has to be on, right? What I'm saying is this is a legitimate option to pursue, and there could be other options available. There are other options. There's many pathways to recovery. It doesn't really matter how someone gets there. It's quite possible that these groups won't work for somebody, then we should not make them feel bad. We should try to help them find something else. It is also not the case that because we have this, we don't need the rest of the care system. Of course we do. Some people need medications, not just for addiction, but for lots of other things. Some people need really detailed psychiatric care that they're not going to get there. Some people need treatment for hepatitis. So it should not be used, let's say, for example, by a budget-conscious politician saying, we'll just rely on this free stuff and not fund health care. That's not the proper conclusion. I'll just say a little before I close about the non-12-step. I'm very interested in these. I'm highly supportive of them. In fact, the first studies that were ever done on one of them were done by me because I was so interested. Patients are diverse. People with these problems are diverse. It would be cool to have more options because there's some people, they see the 12-step, they see the spiritual stuff, like, I don't like that, or they don't like something else about it. We need more options for them. So there's some descriptive studies. My friend Leanne Kaskudas and her colleagues have done some really nice ones of women for sobriety, which is, as you guessed, all women tends to attract maybe college-educated people with a fair amount of social stability. And it rejects the 12-steps and instead has the 14 affirmations based on sort of building up a woman's confidence and sense of worth. Moderation management is a group I've studied, which basically uses cognitive behavioral techniques and rational motive techniques to help people. The difference being that it's not an abstinence-focused organization. It can become abstinent, but actually their goal, if they figure out most people, is people who drink too much and they want to drink moderately. Again, it tends to also draw a pretty socially stable group. The level of alcohol problems you see in moderation management is a bare fraction of what you typically see in AA. Here's a nice study by Sarah Zimor, and the full reference info is there, but this is a correlation study, but I think a really encouraging one of looking at people who had been through these different organizations as well as LifeRing, which was an organization biggest out here in California, but exists other places. Smart Recovery, which is a cognitive behavioral driven organization, and it's an approach that is available increasingly around the U.S. But anyway, it showed benefits, at least comparable correlational benefits across all those different organizations for people who had alcohol use disorder. And John Kelly, who led the Cochran Review, is, I'm happy to say, has gotten a grant to do a quite rigorous study of Smart Recovery with a really large sample and a good chance to draw an inference and a chance to look at the mechanisms of behavior change that produce if there are benefits. And if I had to place a bet, I would bet there will be benefits because there's a lot of parallels even though the philosophy is different in Smart. You have the humanity, the gathering together, the support, the hope, inspiration is there as it is in AA, so I expect it will work. But he's going to have some nice measures about how that is, as well as looking at degree of benefit across different groups and what might modify why some people gain more from it than others. So we're learning more about non-12-step groups, and that is certainly good. So to wrap up the talk, we can say that Alcoholics Anonymous significantly reduces substance use and health. And I want to emphasize, I'm not saying is associated with, correlated with. I'm saying reduces. That's a causal statement. We can definitely say that, as surely as we can say antibiotics, you know, wipe out bacteria, we can say AA reduces substance use and health care costs, causal statement. How that happens, well, there's mediators that are psychological, and there's mediators that are social. So some of it can be about my motivation, my interest, my coping skills, but also the fact I'm on a journey with other people who support me along the way, and that certainly helps. So that is certainly a great thing to have, and as I said, that does not mean every single human being with a substance use or alcohol problem has to go to 12-step. We also need these non-12-step alternatives. It's good that we're studying them, presuming we show they're beneficial, we should be recommending them just as much as an option for patients to pursue as much as we do Alcoholics Anonymous. Here's some readings that you can look at. And the 12-step Cytotoxin Therapeutic Manual is produced by NIAAA, you can get it from them, and that's free. Also, as I mentioned, the Cochrane thing is free, and my book is, you know, pretty old, I think you can get it. It's not free, but, you know, I'm sure you can find it pretty cheap on my copy. So I hope those might be helpful to you. Thanks for attending this, and thanks for your interest, and I wish you the very best in your work.

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