A randomized controlled trial of intensive referral to 12-step self-help groups: one-year outcomes

Meeting-makers make meaning: alcoholics anonymous participation and personal meaningfulness

AIMS

The central aim of this study was to determine whether intentional, voluntary alcoholics anonymous (AA) participation showed any independent association with affect, over and above that which has been observed in association with other recovery-related behaviors, such as abstinence, among individuals with a history of alcohol use disorder. Additionally, we sought to determine the nature of the affective changes associated with specific dimensions of AA participation (i.e. meeting  attendance, fellowship  involvement, 12-step  work).

METHODS

Thirty abstinent alcohol use disorder individuals were recruited and evaluated. Multivariate linear regressions were used to examine associations between dimensions of AA participation, measured using the Multidimensional Mutual-Help Assessment Scale and standardized measures of affective experiences, including the Profile of Mood States, Subjective Happiness Scale, and the Twelve Promises Scale.

RESULTS AND CONCLUSIONS

Increase in AA participation was associated with higher positive affective experiences. These associations were observed independently with AA meeting  attendance and fellowship  involvement, but not 12-step work. This study's findings suggest that greater AA meeting  attendance and fellowship  involvement are correlated with enhancements in the meta-emotional experience of personal meaningfulness. This study extends evidence on AA-related changes by considering affective improvements as a primary clinical outcome, thereby laying the foundation for subsequent, more comprehensive research into the relationship between dimensions of AA participation and recovery-related affective changes.

Piloting the integration of SMART Recovery into outpatient alcohol and other drug treatment programs

BACKGROUND

Research suggests peer support groups can amplify and extend treatment effects and enhance long-term recovery from Alcohol and Other Drug (AOD) problems. However, they are rarely integrated into outpatient treatment programs, resulting in a missed opportunity for peer-to-peer learning, and increased connection to others social networks where people want to reduce or cease substance use.

METHOD

In this mixed-methods study, we examined the uptake, participant experiences and impacts of Self-Management and Recovery Training (SMART) when embedded in three public AOD treatment programs in a pilot program in Australia. Groups were delivered initially in-person but transitioned online during the COVID-19 pandemic.

RESULTS

A total of 75 SMART Recovery groups were run by the pilot sites, with an average attendance of 6.5 people per meeting. Among Participants (N = 31) who completed the survey, 94% reported benefits relating to substance use (i.e., reduction/ successful maintenance of abstinence), 71% reported improvements in their mental health and wellbeing, 74% reported improvements in their physical health, and 81% reported feeling better connected with others. In-depth qualitative interviews were conducted with 10 participants to explore their experiences. Thematic analysis revealed four themes: motivation to attend, active ingredients, views on the integration of SMART into formal AOD, and the advantages and disadvantages of online groups.

CONCLUSION

Taken together, these findings suggest embedding SMART Recovery in AOD treatment is a worthwhile endeavour. This was indicated by a good uptake and evidence of multiple and unique benefits to participants over and above their usual care, notably, better management of their AOD use, health, wellbeing, and sense of connection with others.

Predicting Response to Services for Homeless Adolescents and Transition Age Youth (TAY) with Substance Use And/Or Mental Health Disorders: Implications for Youth Treatment and Recovery

PURPOSE

This paper examines patterns of response to a multi-disciplinary wrap-around program for homeless adolescents and transition-aged youth with substance use and/or mental health disorders.

METHOD

A cluster analysis of outcome data from 148 youth was conducted.

RESULTS

Cluster 1 (n = 67) demonstrated significant decreases in risky behavior (e.g., engaging in unprotected sex, crime, and substance use) and poor interpersonal relationships (e.g. more interaction with family and friends and lower rates of violence) but experienced relatively fewer interactions with family and friends. Cluster 2 (n = 57) demonstrated a significant decrease in poor life functioning (e.g., lower rates of employment/education, better quality of life, and less symptoms of internalizing disorders). Cluster 3 (n = 24) experienced significant increases in risky behavior, poor life functioning, and poor interpersonal relationships.

DISCUSSION

Clusters 1 and 2 improved over six months of care. Cluster 3 deteriorated despite receiving similar services and used more opioids and stimulants.

CONCLUSIONS

Peer engagement in programs for this population are important. Recommendations for cluster 3 include targeted outreach, medication assisted treatment, and additional research-supported treatments. Further research is needed to test these interventions over longer periods of time.

The Involvement in Alcoholics Anonymous Scale - Short Form: Factor Structure & Validation

Background: The aim of this research was to examine the psychometrics of a short form version of the multidimensional Involvement in Alcoholics Anonymous scale (IAA-SF) by assessing the factor structure, internal consistency, and predictive validity. While there are several existing measures of involvement in Alcoholics Anonymous, many are either unidimensional or are limited in their ability to gather variation in the level of involvement in the different dimensions of 12-step programs. Objective: To achieve our aim, we used exploratory and principal axis factor analysis, correlation, and logistic regression with two unique and diverse samples. Longitudinal data were collected from a northern Illinois sample of 110 post-treatment adults, and cross-sectional data were from a random sample of 296 recovery home residents in the United States. Results: Results from the first sample suggested three exploratory factors (Principles Involvement, Social Involvement, and Spiritual Involvement) that were concordant with the proposed conceptualization and were then confirmed in the second sample. A 2nd order factor of global involvement was also found. All subscales demonstrated good to excellent internal consistency and were moderately associated with AA affiliation. Global and social involvement predicted greater odds of abstinence 2 years later, but principles and spiritual involvement did not. Conclusion: Overall results suggest the IAA- SF is a valid and reliable 12-item instrument for assessing involvement in the AA program, and the differential prediction suggests potential utility for a multidimensional approach to 12-step involvement.

Understanding recovery Capital in relation to categorical 12-Step involvement and abstinence social support

Background

Although recovery capital represents various resources for persons recovering from substance use disorders, measures of this construct examine components that might not necessarily reflect the recovery goals of individuals who base their recovery through involvement in 12-step groups such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). It is not clear whether 12-step involvement is related to recovery capital, particularly among individuals living in recovery homes who utilize social networks of recovering peers for their recovery. Thus, categorical involvement in a set of 12-step activities was examined in relation to recovery capital and abstinence social support.

Methods

Differences in terms of general (recovery capital scores, retention rates) and abstinence-specific (abstinence social support) resources were examined in relation to recovery home residents who were (n = 395) and were not (n = 232) categorically involved in their 12-step recovery.

Results

Residents with categorical 12-step involvement reported significantly higher levels of recovery capital and abstinence social support, and there was no significant difference observed in retention rates between residents who were/were not categorically involved in 12-step groups.

Conclusions

Findings suggest community resources such as recovery homes and categorical involvement in 12-step groups are important recovery capital components that help individuals who use a 12-step approach to their recovery. Recovery capital among those involved with 12-step fellowships such as AA and NA should be assessed by examining abstinence-specific components such as representative involvement in 12-step groups and social support that is abstinence-specific.

Predictors of alcohol use disorder treatment outcomes over 12 months: Role of concerned others' functioning and Al-Anon participation

BACKGROUND

This study included dyads comprised of adults entering treatment for alcohol use disorder and their Concerned Others (COs) to examine indicators of COs functioning (Al-Anon attendance and involvement, relationship stressors, use of approach coping and stigma) as predictors of patient outcomes (Alcoholics Anonymous (AA) attendance and involvement, abstinence and risk of substance use) over 12 months following adults' entry into AUD treatment.

METHODS

Dyads (n = 279) were assessed when patients entered treatment and at 3-, 6- and 12-month follow-ups. Data were collected through participants' self-report. Lagged generalized linear mixed models were used to examine associations between indicators of COs' functioning at baseline, 3- and 6-month follow-ups and patients' outcomes at 3-, 6- and 12-month follow-ups.

RESULTS

Patients reported less AA attendance and involvement and likelihood of maintaining abstinence from alcohol use over time. Findings from our multivariate analysis showed that any CO involvement in Al-Anon, relative to none, was associated with more patient AA attendance. In contrast, more stigma (e.g., need to hide patient's drinking) reported by COs was associated with lower patient AA participation and involvement, while more CO use of approach coping was associated with less patient risk for alcohol and drug use.

CONCLUSIONS

Findings suggest that COs' functioning can affect longer-term outcomes of adults entering AUD treatment. Treatment programs should increase the availability of help to COs to improve their functioning and patient outcomes.

Al-Anon Intensive Referral to facilitate concerned others' participation in Al-Anon Family Groups: a randomized controlled trial

AIMS

To test the effectiveness of an intervention, Al-Anon Intensive Referral (AIR), to facilitate participation in Al-Anon Family Groups (Al-Anon).

DESIGN, SETTING AND PARTICIPANTS

Multi-site, randomized controlled trial of AIR versus usual care (UC), with follow-up assessments at 3, 6 and 12 months. The 12-month follow-up rate was 74%. Residential alcohol use disorder (AUD) treatment programs in three US locations. Concerned others (COs) of patients in treatment for AUD. COs were mainly women (77%) who were patients' spouses (33%) or parents (25%).

INTERVENTION AND COMPARATOR

AIR (n = 128) consisted of four sessions over 3 months with an Al-Anon coach. UC (n = 151) was the treatment program's offer of educational sessions for COs.

MEASUREMENTS

Primary outcome: COs' self-reports of any Al-Anon attendance (yes or no) at 3 months.

SECONDARY OUTCOMES

number of Al-Anon meetings and the CO-patient relationship (stressors, resources). Potential predictors of outcomes examined in generalized linear mixed models were their baseline value, time, CO-patient relationship type (marital or non-marital), treatment program and condition.

FINDINGS

There was no effect of condition for the primary outcome (28% in AIR, 21% in UC; Bayes factor = 1.86). Relationship stressors at follow-ups were more severe for COs in a marital relationship with the patient than for COs in a non-marital relationship [β = 2.19, 95% confidence interval (CI) = 1.07, 3.32]. For CO-patient relationship resources at follow-ups, the main effect for condition was significant (β = 1.33, 95% CI = 0.04, 2.61). COs assigned to the AIR condition had more resources than COs who were in the UC condition.

CONCLUSIONS

Relative to usual care, Al-Anon Intensive Referral was not associated with increases in participation of concerned others in Al-Anon, but was associated with more resources in the concerned other-patient relationship.

Augmenting substance use treatment in the drug court: A pilot randomized trial of peer recovery support

INTRODUCTION

Peer recovery specialist (PRS) support has been used to varying degrees in community substance use and mental health treatment for a number of years. Although there has been some evidence of positive PRS impacts on client outcomes, previous research has shown inconsistent findings and methodological shortcomings. Given the high prevalence of substance use disorders among people involved in the criminal justice system, and limited available treatment opportunities, PRS support could provide a cost-effective opportunity to promote positive client outcomes. Drug courts, with their focus on treatment and rehabilitation rather than punishment, are an ideal laboratory to test the impacts of PRS on substance use recurrence and recidivism.

METHODS

The present study is, to our knowledge, the first experimental test of the PRS model in a justice system setting. We implemented a pilot experiment in the Philadelphia Treatment Court, randomizing 76 drug court participants to be linked to a PRS or to services as usual, and analyzed client outcomes over a nine-month follow-up period. Most participants' drug of choice was marijuana.

RESULTS

The results showed a reduction in rearrests and improvement in drug court engagement, but no impact on substance use recurrence or treatment engagement.

CONCLUSIONS

The mixed findings suggest some promise for the PRS model in the drug court setting, but the need for further research with more diverse and higher-risk drug court populations.

Targeting the Barriers in the Substance Use Disorder Continuum of Care With Peer Recovery Support

Substance Use Disorder (SUD) has been recognized as a chronic, relapsing disorder. However, much of existing SUD care remains based in an acute care model that focuses on clinical stabilization and discharge, failing to address the longer-term needs of people in recovery from addiction. The high rates of client’s disengagement and attrition across the continuum of care highlight the need to identify and overcome the obstacles that people face at each stage of the treatment and recovery process. Peer recovery support services (PRSS) show promise in helping people initiate, pursue, and sustain long-term recovery from substance-related problems. Based on a comprehensive review of the literature, the goal of this article is to explore the possible roles of peers along the SUD care continuum and their potential to improve engagement in care by targeting specific barriers that prevent people from successfully transitioning from one stage to the next leading eventually to full recovery. A multidimensional framework of SUD care continuum was developed based on the adapted model of opioid use disorder cascade of care and recovery stages, within which the barriers known to be associated with each stage of the continuum were matched with the existing evidence of effectiveness of specific PRSSs. With this conceptual paper, we are hoping to show how PRSSs can become a complementary and integrated part of the system of care, which is an essential step toward improving the continuity of care and health outcomes.

Helping Clients Engage With Remote Mutual Aid for Addiction Recovery During COVID-19 and Beyond

Face-to-face mutual-aid meetings such as Alcoholics Anonymous shuttered with the onset of COVID-19. Research could not be conducted quickly enough to provide guidance for how to respond. However, two powerful tools could be leveraged: the research on mutual aid conducted before the pandemic and the vast number of virtual resources that proliferated with the onset of the pandemic. This article reviews the existing mutual aid research and its relevance to COVID-19, describes the diverse array of virtual resources, and provides recommendations for successful engagement with virtual mutual aid during COVID-19 and beyond.

Warm Handoffs for Improving Client Receipt of Services: A Systematic Review

INTRODUCTION

Warm handoffs intend to improve receipt of services by clients who receive referrals to services that are stigmatized or not easily accessible. Such strategies are characterized as the handoff or transfer of an individual between two service providers through a face-to-face, phone, or technology-assisted interaction. This approach may be useful for maternal and child health home visitors who provide direct services and facilitate connections to community resources for client families. However, little is known about the effectiveness of warm handoffs.

METHODS

A systematic review of the literature on warm handoffs was conducted with studies identified in four databases. Full text was reviewed for studies for which abstracts met inclusion criteria or for which abstracts were not available. Evidence tables summarizing study characteristics, outcome measures and data sources, intervention descriptions, intervention components, and study results were constructed.

RESULTS

Of the 42,816 unique articles identified, 32,163 titles/abstracts were screened, 227 qualified for full text review, and five comprised the study sample. Three studies examined referrals from substance use treatment centers to self-help groups, one from federally qualified health centers to community mental health clinics, and one from a mobile needle exchange program to substance use treatment/intake. Three studies showed increases in receipt of services by clients following referral between the warm handoff intervention and control group.

DISCUSSION

Current evidence regarding the effectiveness of warm handoffs is limited. An examination of the effectiveness of warm handoffs in the context of home visits is needed to assess whether they facilitate client referrals.

An Apologetic Interpretation of Alcoholics Anonymous (AA): Timeless Wisdom, Outdated Language

BACKGROUND

The Twelve Steps of Alcoholics Anonymous (AA) has proven to be an effective aid in recovery for many people with alcohol use disorder. While constructive criticisms of AA can be beneficial to the organization, other criticisms have merely served as rhetorical devices intent on discrediting the 12-step approach.

OBJECTIVES

This paper examines six prominent critiques of AA, paying special attention to the premises, tone, and factual basis of the statements. Interpretations grounded in AA literature are offered to address claims or critiques around prominent themes, which are organized into two main classes: purported causes of alcoholism and factors maintaining alcoholism.

RESULTS

Findings reveal tenuous statements in the AA literature that appear contradictory and thereby invite a misreading. These statements, some of which misrepresent the tenets of AA and its founders, underscore certain vocal criticisms that are not entirely unfounded. While many pages of the AA literature are imbued with timeless wisdom, even the most apologetic interpretations-distilled into benefit-of-the-doubt renderings-largely falter in defending the nature of the language that originated in the early 1900s at odds with 21st century understandings of alcohol use disorder. Conclusions/Importance: The AA literature essentially presents a valid target for critics, fueling resistance to this free community-based resource that may prevent people who could benefit from AA from seeking the help of the 12-steps.

Alcoholics Anonymous and 12-Step Facilitation Treatments for Alcohol Use Disorder: A Distillation of a 2020 Cochrane Review for Clinicians and Policy Makers

AIMS

A recently completed Cochrane review assessed the effectiveness and cost-benefits of Alcoholics Anonymous (AA) and clinically delivered 12-Step Facilitation (TSF) interventions for alcohol use disorder (AUD). This paper summarizes key findings and discusses implications for practice and policy.

METHODS

Cochrane review methods were followed. Searches were conducted across all major databases (e.g. Cochrane Drugs and Alcohol Group Specialized Register, PubMed, Embase, PsycINFO and ClinicalTrials.gov) from inception to 2 August 2019 and included non-English language studies. Randomized controlled trials (RCTs) and quasi-experiments that compared AA/TSF with other interventions, such as motivational enhancement therapy (MET) or cognitive behavioral therapy (CBT), TSF treatment variants or no treatment, were included. Healthcare cost offset studies were also included. Studies were categorized by design (RCT/quasi-experimental; nonrandomized; economic), degree of manualization (all interventions manualized versus some/none) and comparison intervention type (i.e. whether AA/TSF was compared to an intervention with a different theoretical orientation or an AA/TSF intervention that varied in style or intensity). Random-effects meta-analyses were used to pool effects where possible using standard mean differences (SMD) for continuous outcomes (e.g. percent days abstinent (PDA)) and the relative risk ratios (RRs) for dichotomous.

RESULTS

A total of 27 studies (21 RCTs/quasi-experiments, 5 nonrandomized and 1 purely economic study) containing 10,565 participants were included. AA/TSF interventions performed at least as well as established active comparison treatments (e.g. CBT) on all outcomes except for abstinence where it often outperformed other treatments. AA/TSF also demonstrated higher health care cost savings than other AUD treatments.

CONCLUSIONS

AA/TSF interventions produce similar benefits to other treatments on all drinking-related outcomes except for continuous abstinence and remission, where AA/TSF is superior. AA/TSF also reduces healthcare costs. Clinically implementing one of these proven manualized AA/TSF interventions is likely to enhance outcomes for individuals with AUD while producing health economic benefits.

Implementing peer recovery coaching and improving outcomes for substance use disorders in underserved communities

INTRODUCTION

The Peer Recovery Expansion Project (PREP) was designed to expand outreach and deliver enhanced treatment services via peer-recovery coaches for individuals with substance use disorder (SUD) and limited access to healthcare.

METHODS

PREP was implemented in low-socioeconomic areas with historic challenges to accessing SUD treatment. Services were provided to 153 clients through tailored cultural responsiveness, use of peer-based recovery coaching, and development of a Recovery Support Network. Outcome data were collected using the Government Performance and Reporting Act tool at intake and at 6-month follow-up for coaches and clients.

RESULTS

The vast majority of peer-recovery coaches were satisfied with the overall quality of the training and their training experience (96.8%). Around 95% agreed that the training enhanced their skills in the topic area and 93% agreed that the training was relevant to substance use disorder treatment at the 6-month post training survey. Majority of clients were from low-income, minority demographics that had a high prevalence history of incarceration, homelessness, and inconsistent employment. At 6-month follow-up, they reported a 22% increase in stable housing and a 25% increase in full-time/part-time employment/training program enrollment. They also demonstrated a significant decline in reported depression, anxiety, and prescribed medication use at 6-month follow-up when compared to baseline.

CONCLUSIONS

Clients enrolled in a tailored evidence based peer-led program decreased their psychiatric symptoms and increased their housing stability and employment. Study outcomes support the use of an integrated peer-led support for increasing engagement in care for adults experiencing substance use disorders.

Alcoholics Anonymous and other 12-step programs for alcohol use disorder

BACKGROUND

Alcohol use disorder (AUD) confers a prodigious burden of disease, disability, premature mortality, and high economic costs from lost productivity, accidents, violence, incarceration, and increased healthcare utilization. For over 80 years, Alcoholics Anonymous (AA) has been a widespread AUD recovery organization, with millions of members and treatment free at the point of access, but it is only recently that rigorous research on its effectiveness has been conducted.

OBJECTIVES

To evaluate whether peer-led AA and professionally-delivered treatments that facilitate AA involvement (Twelve-Step Facilitation (TSF) interventions) achieve important outcomes, specifically: abstinence, reduced drinking intensity, reduced alcohol-related consequences, alcohol addiction severity, and healthcare cost offsets.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group Specialized Register, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, CINAHL and PsycINFO from inception to 2 August 2019. We searched for ongoing and unpublished studies via ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) on 15 November 2018. All searches included non-English language literature. We handsearched references of topic-related systematic reviews and bibliographies of included studies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs), quasi-RCTs and non-randomized studies that compared AA or TSF (AA/TSF) with other interventions, such as motivational enhancement therapy (MET) or cognitive behavioral therapy (CBT), TSF treatment variants, or no treatment. We also included healthcare cost offset studies. Participants were non-coerced adults with AUD.

DATA COLLECTION AND ANALYSIS

We categorized studies by: study design (RCT/quasi-RCT; non-randomized; economic); degree of standardized manualization (all interventions manualized versus some/none); and comparison intervention type (i.e. whether AA/TSF was compared to an intervention with a different theoretical orientation or an AA/TSF intervention that varied in style or intensity). For analyses, we followed Cochrane methodology calculating the standard mean difference (SMD) for continuous variables (e.g. percent days abstinent (PDA)) or the relative risk (risk ratios (RRs)) for dichotomous variables. We conducted random-effects meta-analyses to pool effects wherever possible.

MAIN RESULTS

We included 27 studies containing 10,565 participants (21 RCTs/quasi-RCTs, 5 non-randomized, and 1 purely economic study). The average age of participants within studies ranged from 34.2 to 51.0 years. AA/TSF was compared with psychological clinical interventions, such as MET and CBT, and other 12-step program variants. We rated selection bias as being at high risk in 11 of the 27 included studies, unclear in three, and as low risk in 13. We rated risk of attrition bias as high risk in nine studies, unclear in 14, and low in four, due to moderate (> 20%) attrition rates in the study overall (8 studies), or in study treatment group (1 study). Risk of bias due to inadequate researcher blinding was high in one study, unclear in 22, and low in four. Risks of bias arising from the remaining domains were predominantly low or unclear. AA/TSF (manualized) compared to treatments with a different theoretical orientation (e.g. CBT) (randomized/quasi-randomized evidence) RCTs comparing manualized AA/TSF to other clinical interventions (e.g. CBT), showed AA/TSF improves rates of continuous abstinence at 12 months (risk ratio (RR) 1.21, 95% confidence interval (CI) 1.03 to 1.42; 2 studies, 1936 participants; high-certainty evidence). This effect remained consistent at both 24 and 36 months. For percentage days abstinent (PDA), AA/TSF appears to perform as well as other clinical interventions at 12 months (mean difference (MD) 3.03, 95% CI -4.36 to 10.43; 4 studies, 1999 participants; very low-certainty evidence), and better at 24 months (MD 12.91, 95% CI 7.55 to 18.29; 2 studies, 302 participants; low-certainty evidence) and 36 months (MD 6.64, 95% CI 1.54 to 11.75; 1 study, 806 participants; low-certainty evidence). For longest period of abstinence (LPA), AA/TSF may perform as well as comparison interventions at six months (MD 0.60, 95% CI -0.30 to 1.50; 2 studies, 136 participants; low-certainty evidence). For drinking intensity, AA/TSF may perform as well as other clinical interventions at 12 months, as measured by drinks per drinking day (DDD) (MD -0.17, 95% CI -1.11 to 0.77; 1 study, 1516 participants; moderate-certainty evidence) and percentage days heavy drinking (PDHD) (MD -5.51, 95% CI -14.15 to 3.13; 1 study, 91 participants; low-certainty evidence). For alcohol-related consequences, AA/TSF probably performs as well as other clinical interventions at 12 months (MD -2.88, 95% CI -6.81 to 1.04; 3 studies, 1762 participants; moderate-certainty evidence). For alcohol addiction severity, one study found evidence of a difference in favor of AA/TSF at 12 months (P < 0.05; low-certainty evidence). AA/TSF (non-manualized) compared to treatments with a different theoretical orientation (e.g. CBT) (randomized/quasi-randomized evidence) For the proportion of participants completely abstinent, non-manualized AA/TSF may perform as well as other clinical interventions at three to nine months follow-up (RR 1.71, 95% CI 0.70 to 4.18; 1 study, 93 participants; low-certainty evidence). Non-manualized AA/TSF may also perform slightly better than other clinical interventions for PDA (MD 3.00, 95% CI 0.31 to 5.69; 1 study, 93 participants; low-certainty evidence). For drinking intensity, AA/TSF may perform as well as other clinical interventions at nine months, as measured by DDD (MD -1.76, 95% CI -2.23 to -1.29; 1 study, 93 participants; very low-certainty evidence) and PDHD (MD 2.09, 95% CI -1.24 to 5.42; 1 study, 286 participants; low-certainty evidence). None of the RCTs comparing non-manualized AA/TSF to other clinical interventions assessed LPA, alcohol-related consequences, or alcohol addiction severity. Cost-effectiveness studies In three studies, AA/TSF had higher healthcare cost savings than outpatient treatment, CBT, and no AA/TSF treatment. The fourth study found that total medical care costs decreased for participants attending CBT, MET, and AA/TSF treatment, but that among participants with worse prognostic characteristics AA/TSF had higher potential cost savings than MET (moderate-certainty evidence).

AUTHORS' CONCLUSIONS

There is high quality evidence that manualized AA/TSF interventions are more effective than other established treatments, such as CBT, for increasing abstinence. Non-manualized AA/TSF may perform as well as these other established treatments. AA/TSF interventions, both manualized and non-manualized, may be at least as effective as other treatments for other alcohol-related outcomes. AA/TSF probably produces substantial healthcare cost savings among people with alcohol use disorder.

Peer support specialists and perinatal opioid use disorder: Someone that's been there, lived it, seen it

Perinatal opioid use disorder (OUD) has increased drastically since 2000 and is associated with myriad adverse outcomes. The Substance Abuse and Mental Health Services Administration (SAMHSA) recommends using peer support services to promote sustained remission from substance use disorders (SUDs). Integrating peer support specialists into perinatal OUD treatment has the potential to improve maternal and child health. However, there is limited published research on the experiences of pregnant and parenting women with peer support specialists during SUD treatment. The purpose of this study was to: (1) describe experiences of perinatal women undergoing OUD treatment with peer support specialists; (2) describe recommendations for improving or enhancing peer support services. For this qualitative descriptive study, we conducted two focus groups in a private location in a clinic that serves postpartum women with OUD (N = 9) who were parenting a child under the age of 5. The focus groups were voice recorded, professionally transcribed, and analyzed in MAXQDA using content analysis. Four themes emerged from the data: Feeling Supported by Peer Support Specialists, Qualities of an 'Ideal' Peer Support Specialist, Strategies to Improve Interactions with Peer Support Specialists, and Importance of Communication Across the Perinatal Period. Participants reported that PSSs had a strong, positive impact on their recovery. Postpartum women report overall positive experiences receiving peer support services during their pregnancy and postpartum period. However, participants offered suggestions to improve their interactions with PSSs, such as clarifying the boundaries between peer supporters and clients. Pregnant and postpartum women in OUD treatment have the potential to benefit from access to PSS throughout their perinatal period. Future research is needed to determine the impact of PSS on sustained recovery for perinatal women with OUD.

Therapeutic efficacy of environmental enrichment for substance use disorders

Addiction to drug and alcohol is regarded as a major health problem worldwide for which available treatments show limited effectiveness. The biggest challenge remains to enhance the capacities of interventions to reduce craving, prevent relapse and promote long-term recovery. New strategies to meet these challenges are being explored. Findings from preclinical work suggest that environmental enrichment (EE) holds therapeutic potential for the treatment of substance use disorders, as demonstrated in a number of animal models of drug abuse. The EE intervention introduced after drug exposure leads to attenuation of compulsive drug taking, attenuation of the rewarding (and reinforcing) effects of drugs, reductions in control of behavior by drug cues, and, very importantly, relapse prevention. Clinical work also suggests that multidimensional EE interventions (involving physical activity, social interaction, vocational training, recreational and community involvement) might produce similar therapeutic effects, if implemented continuously and rigorously. In this review we survey preclinical and clinical studies assessing the efficacy of EE as a behavioral intervention for substance use disorders and address related challenges. We also review work providing empirical evidence for EE-induced neuroplasticity within the mesocorticolimbic system that is believed to contribute to the seemingly therapeutic effects of EE on drug and alcohol-related behaviors.

Effects of 12-step mutual support and professional outpatient services on short-term substance use outcomes among adults who received inpatient treatment

BACKGROUND

Continuing care is increasingly prioritized in the treatment of substance use disorders (SUDs). Ongoing engagement in continuing care, including mutual support (e.g., 12-step groups) and/or professional outpatient services, may enhance treatment outcomes and facilitate recovery.

OBJECTIVE

This study investigates how engagement in 12-step mutual support and professional outpatient services is associated with short-term substance use outcomes in a sample of patients who completed inpatient SUDs treatment.

METHODS

As part of the Recovery Journey Project - a longitudinal cohort study - participants completed questionnaires upon admission to an inpatient SUDs treatment program, and at 1- and/or 3-months post-discharge (n = 379). Baseline data were collected by self-administered, electronic questionnaires. Follow up data were collected by phone or email. Analyses involved multivariate Generalized Estimating Equations separately modelling self-reported abstinence and percent days abstinent (PDA) over the three time periods.

RESULTS

Overall, rates of self-reported abstinence and PDA increased significantly from baseline to 1- and 3-months follow up. Engagement in 12-step activities (i.e., attended 30 meetings in 30 days, had a home group, had a sponsor, did service work) and professional outpatient substance use support were each significantly associated with abstinence and PDA. Participants who reported a higher degree of 12-step involvement (defined as engagement in more 12-step activities) were also more likely to report being abstinence and greater PDA.

CONCLUSIONS

Engagement in continuing care, including 12-step activities and professional outpatient substance use support, was highly associated with substance use. Clinical teams should encourage participation in such activities to optimize treatment outcomes.

Affiliation to alcoholics anonymous or narcotics anonymous among patients attending an English specialist addiction service

Purpose

Attendance at alcoholics anonymous (AA) or narcotics anonymous (NA) meetings and affiliation with the fellowship has potential benefits for people with alcohol or drug use disorders. This effect is present whether or not the individual attends professional treatment services, but the two process can have a synergistic effect. Limited information exists about the extent to which people attending UK specialist treatment services also attend AA/NA and their views about such attendance. The paper aims to discuss these issues.

Design/methodology/approach

A cross-sectional survey of 200 consecutive attendees at the specialist treatment service in an English region was conducted between January and April 2018. A measure of past attendance and affiliation with AA/NA (AAAS) and a scale designed to quantify future readiness to attend (Survey of Readiness for Alcoholics Anonymous Participation) were administered and anonymously linked to data supplied to the National Drug Treatment Monitoring Service (NDTMS).

Findings

A minority of the sample had ever attended an AA meeting (31 per cent, n=59) or an NA meeting (41 per cent, n=79), and only 14 per cent (n=27) and 24 per cent (n=45) had attended an AA or NA meeting, respectively, in the past year. Only two variables significantly predicted level of readiness to attend AA or NA in a regression model: attended more AA/NA meetings in the past (ß=0.149, p=0.036) and previous level of participation (AAAS score) (ß=0.409, p < 0.001).

Practical implications

A significant proportion of attendees of a specialist drug and alcohol treatment service had never attended AA/NA, despite many positive views about their potential benefits. Given the established benefits of attending AA/NA meetings and participating in the AA or NA fellowship, these results suggest that professional treatment services should do more to explain the process and challenge preconceived ideas about how they operate.

Originality/value

The authors are not aware of any published research that captures the rates of attendance of and participation in both AA and NA groups in a UK-based community treatment sample. These results may therefore provide a baseline for evaluating the impact of interventions to increase attendance/participation, and also provide some insight into the potential barriers to attendance in this population.

Effects of Social Support and 12-Step Involvement on Recovery among People in Continuing Care for Cocaine Dependence

Background: Social networks that support recovery lead to enhanced treatment outcomes and sobriety regardless if this support stems from family, peer groups or 12-Step programs. Treatment process factors including readiness to change and commitment to abstinence also impact substance use. However, little is understood about the relationship between social support to treatment process factors during and after treatment for substance use disorders. Objectives: To identify the ways in which different social networks foster substance use change in a sample of individuals with cocaine dependence from intensive outpatient programs (IOPs). Methods: Data were drawn from two studies examining adults (N = 489) with cocaine dependence in IOPs for substance use disorders collected between 2004 and 2009. Assessment data were collected at 3- to 6-month intervals from baseline to 24-months and included the University of Rhode Island change assessment questionnaire, timeline followback, thoughts about abstinence, perceived social support - friend, and family versions and analyzed using GEE and mediational analyses. Results: Greater perceived friend social support was associated with greater readiness to change whereas greater perceived familial social support was associated with substance use goal; greater social support from both friends and family were associated with less substance use. Greater AA/NA participation was associated with substance use goal and readiness to change, and less substance use. Substance use goals partially mediated the impact of social support on later substance use. Conclusions/Importance: While peer and familial support are key to sustained recovery, their impact differentially affects treatment process variables. This information could be used to inform social support treatment interventions.

Lived Experience in New Models of Care for Substance Use Disorder: A Systematic Review of Peer Recovery Support Services and Recovery Coaching

Peer recovery support services (PRSS) are increasingly being employed in a range of clinical settings to assist individuals with substance use disorder (SUD) and co-occurring psychological disorders. PRSS are peer-driven mentoring, education, and support ministrations delivered by individuals who, because of their own experience with SUD and SUD recovery, are experientially qualified to support peers currently experiencing SUD and associated problems. This systematic review characterizes the existing experimental, quasi-experimental, single- and multi-group prospective and retrospective, and cross-sectional research on PRSS. Findings to date tentatively speak to the potential of peer supports across a number of SUD treatment settings, as evidenced by positive findings on measures including reduced substance use and SUD relapse rates, improved relationships with treatment providers and social supports, increased treatment retention, and greater treatment satisfaction. These findings, however, should be viewed in light of many null findings to date, as well as significant methodological limitations of the existing literature, including inability to distinguish the effects of peer recovery support from other recovery support activities, heterogeneous populations, inconsistency in the definitions of peer workers and recovery coaches, and lack of any, or appropriate comparison groups. Further, role definitions for PRSS and the complexity of clinical boundaries for peers working in the field represent important implementation challenges presented by this novel class of approaches for SUD management. There remains a need for further rigorous investigation to establish the efficacy, effectiveness, and cost-benefits of PRSS. Ultimately, such research may also help solidify PRSS role definitions, identify optimal training guidelines for peers, and establish for whom and under what conditions PRSS are most effective.

Le soutien des pairs souffrant de psychose : l’expérience du programme « Passer l’espoir au suivant »

Pour les personnes souffrant d’un trouble de santé mentale, le soutien de pairs aidants (au sens de personnes s’étant rétablies d’un tel trouble) est d’une grande valeur thérapeutique. Les Alcooliques anonymes (AA) ont été les premiers à le démontrer. Leur approche comporte plusieurs éléments bénéfiques, tel les « meetings », le programme en « 12 étapes », et un élément majeur, le parrainage d’un individu par un pair. Depuis sont apparues des organisations reposant sur des groupes de pairs, et aussi cette nouvelle profession de « pair aidant ». Dans le contexte d’un centre de traitement pour personnes souffrant de troubles psychotiques majeurs, pour lesquels l’espoir est un ingrédient déterminant du rétablissement, l’article présente ici un programme d’entraide s’appuyant principalement sur un parrainage d’un client par un pair et qui, depuis son introduction, commence cliniquement à porter ses fruits. Le programme a aussi une composante de « meetings » et une composante des « 12 étapes ».

Helpful Ingredients in the Treatment of Long-Term Substance Use Disorders: A Collaborative Narrative Study

Relatively few individuals with a substance use disorder (SUD) seek or receive treatment, and knowledge about the effective ingredients in SUD treatment, from the perspective of those who receive it, is scarce. Our study purpose was to explore the experiences of those with long-term SUDs and the aspects they found helpful during treatment and long-term recovery. Semi-structured interviews were conducted with 18 participants, each of whom had been diagnosed with a long-term SUD, and who had been abstinent for at least 5 years. A resource group of peer consultants in long-term recovery from SUDs contributed to study planning, preparation, and initial analyses. Participants preferred individualized, long-term treatment, and support from both therapists and other clients. They further acknowledged the importance of their own sense of responsibility for their treatment and recovery success. Greater focus should be placed on viewing long-term SUD as a long-term condition, similar to somatic diseases, and SUD treatment services should place greater emphasis on developing partnership care models, long-term monitoring and support, and actively engaging recovered clients in the care of others in SUD treatment.

A longitudinal study of the comparative efficacy of Women for Sobriety, LifeRing, SMART Recovery, and 12-step groups for those with AUD

BACKGROUND

Despite the effectiveness of 12-step groups, most people reporting a prior alcohol use disorder (AUD) do not sustain involvement in such groups at beneficial levels. This highlights the need for research on other mutual help groups that address alcohol problems and may attract those who avoid 12-step groups. The current study addresses this need, offering outcome data from the first longitudinal, comparative study of 12-step groups and their alternatives: The Peer ALlternatives for Addiction (PAL) Study.

METHODS

Adults with a lifetime AUD were surveyed at baseline (N=647), 6months (81% response rate) and 12months (83% response rate). Members of the largest known secular mutual help alternatives, namely Women for Sobriety (WFS), LifeRing, and SMART, were recruited in collaboration with group directors; current 12-step attendees were recruited from an online meeting hub. Online surveys assessed demographic and clinical variables; mutual help involvement; and alcohol and drug use and severity. Analyses involved multivariate logistic GEEs separately modelling alcohol abstinence, alcohol problems, and total abstinence across 6 and 12months. Key predictors were baseline primary group affiliation (PGA); primary group involvement (PGI) at both baseline and 6months; and the interaction between baseline PGA and 6-month PGI. The critical effects of interest were the interactions, expressing whether associations between changes in PGI from baseline to 6months and substance use outcomes differed by primary group.

RESULTS

None of the interactions between baseline PGA and 6-month PGI were significant, suggesting no differences in the efficacy of WFS, LifeRing, or SMART, vs. 12-step groups. Nevertheless, some PGA main effects emerged. Compared to 12-step members, those identifying SMART as their primary group at baseline fared worse across outcomes, and those affiliating with LifeRing showed lower odds of total abstinence. Still, these effects became nonsignificant when controlling for baseline alcohol recovery goal, suggesting that any group differences may be explained by selection of those with weaker abstinence motivation into LifeRing and (especially) SMART.

CONCLUSIONS

This study makes a valuable contribution in view of the extremely limited evidence on mutual help alternatives. Results tentatively suggest that WFS, LifeRing, and SMART are as effective as 12-step groups for those with AUDs, and that this population has the best odds of success when committing to lifetime total abstinence. An optimal care plan may thus involve facilitating involvement in a broad array of mutual help groups and supporting abstinence motivation.

Effects of Treatment Type on Alcohol Consumption Partially Mediated by Alcoholics Anonymous Attendance

BACKGROUND

As insurance coverage, funding sources and venues for drug and alcohol treatment evolve in the United States, it is important to assess how the type of treatment received may impact long-term outcomes. The current study aims were to examine effects of treatment type on alcohol consumption in the year after treatment intake and to test mediators of effects of treatment type on later alcohol use.

METHODS

Longitudinal data from clients in inpatient and outpatient alcohol treatment programs in California (n = 560) were used in ordinary least squares path analysis adjusting for respondent characteristics typically associated with both treatment completion and alcohol use. The primary outcome was amount of alcohol consumed in the 12 months after treatment entry; hypothesized mediators were treatment duration and participation in Alcoholics Anonymous (AA).

RESULTS

Despite higher baseline problem severity and a shorter treatment duration, inpatient clients consumed less alcohol after treatment than outpatient clients (B [95% CI] = -0.95 [-1.67, -0.23]). AA involvement was a significant mediator of the relationship between treatment type and alcohol consumption, with inpatient clients being more involved in AA and also drinking less after treatment than outpatient clients; the bias-corrected bootstrap 95% confidence interval for the indirect effect (B = -0.20) was entirely below zero (-0.43 to -0.05).

CONCLUSIONS

Outpatient clients may benefit from customized posttreatment recommendations to identify additional resources to assist in the recovery process during the first year after treatment.

Intensive referral to mutual-help groups: A field trial of adaptations for rural veterans

OBJECTIVE

A multisite field trial testing whether improved outcomes associated with intensive referral to mutual help groups (MHGs) could be maintained after the intervention was adapted for the circumstances and needs of rural veterans in treatment for substance use disorder (SUD).

METHODS

In three Veterans Affairs treatment programs in the Midwest, patients (N=195) received standard referral (SR) or rural-adapted intensive referral (RAIR) and were measured at baseline and 6-month follow-up.

RESULTS

Both groups reported significant improvement at 6-months, but no significant differences between SR and RAIR groups in MHG participation, substance use, addiction severity, and posttraumatic stress symptoms. Inconsistent delivery of the intervention resulted in only one-third of the RAIR group receiving the full three sessions, but this group reported significantly greater 6-month abstinence from alcohol than those receiving no sessions.

CONCLUSION

Further research should explore implementation problems and determine whether consistent delivery of the intervention enhances 12-step facilitation.

PRACTICE IMPLICATIONS

The addition of rural-specific elements to the original intensive referral intervention has not been shown to increase its effectiveness among rural veterans.

A pilot randomized clinical trial testing integrated 12-Step facilitation (iTSF) treatment for adolescent substance use disorder

BACKGROUND AND AIMS

The integration of 12-Step philosophy and practices is common in adolescent substance use disorder (SUD) treatment programs, particularly in North America. However, although numerous experimental studies have tested 12-Step facilitation (TSF) treatments among adults, no studies have tested TSF-specific treatments for adolescents. We tested the efficacy of a novel integrated TSF.

DESIGN

Explanatory, parallel-group, randomized clinical trial comparing 10 sessions of either motivational enhancement therapy/cognitive-behavioral therapy (MET/CBT; n = 30) or a novel integrated TSF (iTSF; n = 29), with follow-up assessments at 3, 6 and 9 months following treatment entry.

SETTING

Out-patient addiction clinic in the United States.

PARTICIPANTS

Adolescents [n = 59; mean age = 16.8 (1.7) years; range = 14-21; 27% female; 78% white].

INTERVENTION AND COMPARATOR

The iTSF integrated 12-Step with motivational and cognitive-behavioral strategies, and was compared with state-of-the-art MET/CBT for SUD.

MEASUREMENTS

Primary outcome: percentage days abstinent (PDA); secondary outcomes: 12-Step attendance, substance-related consequences, longest period of abstinence, proportion abstinent/mostly abstinent, psychiatric symptoms.

FINDINGS

Primary outcome: PDA was not significantly different across treatments [b = 0.08, 95% confidence interval (CI) = -0.08 to 0.24, P = 0.33; Bayes' factor = 0.28).

SECONDARY OUTCOMES

during treatment, iTSF patients had substantially greater 12-Step attendance, but this advantage declined thereafter (b = -0.87; 95% CI = -1.67 to 0.07, P = 0.03). iTSF did show a significant advantage at all follow-up points for substance-related consequences (b = -0.42; 95% CI = -0.80 to -0.04, P < 0.05; effect size range d = 0.26-0.71). Other secondary outcomes did not differ significantly between treatments, but effect sizes tended to favor iTSF. Throughout the entire sample, greater 12-Step meeting attendance was associated significantly with longer abstinence during (r = 0.39, P = 0.008), and early following (r = 0.30, P = 0.049), treatment.

CONCLUSION

Compared with motivational enhancement therapy/cognitive-behavioral therapy (MET/CBT), in terms of abstinence, a novel integrated 12-Step facilitation treatment for adolescent substance use disorder (iTSF) showed no greater benefits, but showed benefits in terms of 12-Step attendance and consequences. Given widespread use of combinations of 12-Step, MET and CBT in adolescent community out-patient settings in North America, iTSF may provide an integrated evidence-based option that is compatible with existing practices.

Age differences in outcomes among patients in the "Stimulant Abuser Groups to Engage in 12-Step" (STAGE-12) intervention

Emerging adults (roughly 18-29years) with substance use disorders can benefit from participation in twelve-step mutual-help organizations (TSMHO), however their attendance and participation in such groups is relatively low. Twelve-step facilitation therapies, such as the Stimulant Abuser Groups to Engage in 12-Step (STAGE-12), may increase attendance and involvement, and lead to decreased substance use.

AIMS

Analyses examined whether age moderated the STAGE-12 effects on substance use and TSMHO meeting attendance and participation.

DESIGN

We utilized data from a multisite randomized controlled trial, with assessments at baseline, mid-treatment (week 4), end-of-treatment (week 8), and 3- and 6- months post-randomization.

PARTICIPANTS

Participants were adults with DSM-IV diagnosed stimulant abuse or dependence (N=450) enrolling in 10 intensive outpatient substance use treatment programs across the U.S.

ANALYSIS

A zero-inflated negative binomial random-effects regression model was utilized to examine age-by-treatment interactions on substance use and meeting attendance and involvement.

FINDINGS

Younger age was associated with larger treatment effects for stimulant use. Specifically, younger age was associated with greater odds of remaining abstinent from stimulants in STAGE-12 versus Treatment-as-Usual; however, among those who were not abstinent during treatment, younger age was related to greater rates of stimulant use at follow-up for those in STAGE-12 compared to TAU. There was no main effect of age on stimulant use. Younger age was also related to somewhat greater active involvement in different types of TSMHO activities among those in STAGE-12 versus TAU. There were no age-by-treatment interactions for other types of substance use or for treatment attendance, however, in contrast to stimulant use; younger age was associated with lower odds of abstinence from non-stimulant drugs at follow-up, regardless of treatment condition. These results suggest that STAGE-12 can be beneficial for some emerging adults with stimulant use disorder, and ongoing assessment of continued use is of particular importance.

Study protocol: Community Links to Establish Alcohol Recovery (CLEAR) for women leaving jail

PURPOSE

This article describes the protocol for a randomized effectiveness trial of a method to link alcohol use disordered women who are in pretrial jail detention with post-release 12-step mutual help groups.

BACKGROUND

Jails serve 15 times more people per year than do prisons and have very short stays, posing few opportunities for treatment or treatment planning. Alcohol use is associated with poor post-jail psychosocial and health outcomes including sexually transmitted diseases and HIV, especially for women. At least weekly 12-step self-help group attendance in the months after release from jail has been associated with improvements in alcohol use and alcohol-related consequences. Linkage strategies improve 12-step attendance and alcohol outcomes among outpatients, but have not previously been tested in criminal justice populations.

DESIGN

In the intervention condition, a 12-step volunteer meets once individually with an incarcerated woman while she is in jail and arranges to be in contact after release to accompany her to 12-step meetings. The control condition provides schedules for local 12-step meetings. Outcomes include percent days abstinent from alcohol (primary), 12-step meeting involvement, and fewer unprotected sexual occasions (secondary) after release from jail. We hypothesize that (Minton, 2015) 12-step involvement will mediate the intervention's effect on alcohol use, and (O'Brien, 2001) percent days abstinent will mediate the intervention's effect on STI/HIV risk-taking outcomes. Research methods accommodate logistical and philosophical hurdles including rapid turnover of commitments and unpredictable release times at the jail, possible post-randomization ineligibility due to sentencing, 12-step principles such as Nonaffiliation, and use of volunteers as interventionists.

Comparison of 12-step groups to mutual help alternatives for AUD in a large, national study: Differences in membership characteristics and group participation, cohesion, and satisfaction

BACKGROUND

Many studies suggest that participation in 12-step groups contributes to better recovery outcomes, but people often object to such groups and most do not sustain regular involvement. Yet, research on alternatives to 12-step groups is very sparse. The present study aimed to extend the knowledge base on mutual help group alternatives for those with an alcohol use disorder (AUD), sampling from large, active, abstinence-focused groups including Women for Sobriety (WFS), LifeRing, and SMART Recovery (SMART). This paper presents a cross-sectional analysis of this longitudinal study, using baseline data to describe the profile and participation characteristics of attendees of these groups in comparison to 12-step members.

METHODS

Data from participants 18 and over with a lifetime AUD (N=651) were collected using Web-based surveys. Members of alternative 12-step groups were recruited in collaboration with group directors, who helped publicize the study by emailing meeting conveners and attendees and posting announcements on social media. A comparison group of current (past-30-day) 12-step attendees was recruited from an online meeting hub for recovering persons. Interested parties were directed to a Webpage where they were screened, and eligible participants completed an online survey assessing demographic and clinical variables; in-person and online mutual help involvement; and group satisfaction and cohesion. Analyses involved comparing those identifying WFS, SMART, and LifeRing as their primary group to 12-step members on the above characteristics.

RESULTS

Compared to 12-step members, members of the mutual help alternatives were less religious and generally higher on education and income. WFS and LifeRing members were also older, more likely to be married, and lower on lifetime drug and psychiatric severity; meanwhile, LifeRing and SMART members were less likely to endorse the most stringent abstinence goal. Finally, despite lower levels of in-person meeting attendance, members of all the 12-step alternatives showed equivalent activity involvement and higher levels of satisfaction and cohesion, compared to 12-step members.

CONCLUSIONS

Results suggest differences across 12-step groups and their alternatives that may be relevant when advising clients on a choice of mutual help group. Meanwhile, findings for high levels of participation, satisfaction, and cohesion among members of the mutual help alternatives suggest promise for these groups in addressing addiction problems.

Predictors of 12-Step Attendance and Participation for Individuals With Stimulant Use Disorders

OBJECTIVE

Few studies have examined the effectiveness of 12-step peer recovery support programs with drug use disorders, especially stimulant use, and it is difficult to know how outcomes related to 12-step attendance and participation generalize to individuals with non-alcohol substance use disorders (SUDs).

METHOD

A clinical trial of 12-step facilitation (N=471) focusing on individuals with cocaine or methamphetamine use disorders allowed examination of four questions: Q1) To what extent do treatment-seeking stimulant users use 12-step programs and, which ones? Q2) Do factors previously found to predict 12-step participation among those with alcohol use disorders also predict participation among stimulant users? Q3) What specific baseline "12-step readiness" factors predict subsequent 12-step participation and attendance? And Q4) Does stimulant drug of choice differentially predict 12-step participation and attendance?

RESULTS

The four outcomes variables, attendance, speaking, duties at 12-step meetings, and other peer recovery support activities, were not related to baseline demographic or substance problem history or severity. Drug of choice was associated with differential days of Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) attendance among those who reported attending, and cocaine users reported more days of attending AA or NA at 1-, 3- and 6-month follow-ups than did methamphetamine users. Pre-randomization measures of perceived benefit of 12-step groups predicted 12-step attendance at 3- and 6-month follow-ups. Pre-randomization 12-step attendance significantly predicted number of other self-help activities at end-of-treatment, 3- and 6-month follow-ups. Pre-randomization perceived benefit and problem severity both predicted number of self-help activities at end-of-treatment and 3-month follow-up. Pre-randomization perceived barriers to 12-step groups were negatively associated with self-help activities at end-of-treatment and 3-month follow-up. Whether or not one participated in any duties was predicted at all time points by pre-randomization involvement in self-help activities.

CONCLUSIONS

The primary finding of this study is one of continuity: prior attendance and active involvement with 12-step programs were the main signs pointing to future involvement. Limitations and recommendations are discussed.

Developing and Testing Twelve-Step Facilitation for Adolescents with Substance Use Disorder: Manual Development and Preliminary Outcomes

Adolescent substance use disorder treatment programs are often based on the 12-step philosophy of Alcoholics Anonymous and/or link adolescents to these free resources. Despite this, no studies have developed and rigorously tested a twelve-step facilitation (TSF) intervention for young people, leaving a significant evidence gap. This study describes the first systematic development of an outpatient adolescent TSF treatment. An integrated twelve-step facilitation (iTSF) treatment incorporated TSF, motivational enhancement therapy, and cognitive behavioral therapy elements and was developed in an iterative manner with weekly feedback provided by 36 adolescents (M age 17 years [SD = 1.4]; 52.8% white) with DSM-IV substance use disorder recruited from the community. Assessments were conducted at baseline and at three and six months. Participants completed 6 of 10 sessions on average (8 participants completed all 10). Notable treatment developments were the inclusion of “in-services” led by Marijuana Anonymous members, including parents in a portion of individual sessions to provide a rationale for TSF, and use of a Socratic therapeutic interaction style. Acceptability and feasibility of the treatment were excellent (treatment satisfaction was 4.29 [SD = 0.59] out of 5). In keeping with TSF theory, the intervention substantially increased 12-step participation, and greater participation related to greater abstinence. iTSF is a replicable manualized treatment that can be implemented and tested in outpatient settings. Given the widespread compatibility of iTSF with the current adolescent treatment, if found efficacious, iTSF could be relatively easily adopted, implemented, and sustained and could provide an evidence-based option that could undergird current practice.

A comparison of African American and Caucasian stimulant users in 12-step facilitation treatment

Engagement in 12-step meetings and activities has been shown to be a powerful aid to recovery from substance use disorders. However, only limited attention has been given to ethnic and racial differences in attitudes toward 12-step and involvement. This study utilized data from a large multisite trial testing the effectiveness of a 12-step facilitation therapy with stimulant-dependent treatment seekers. We compared baseline differences and treatment outcomes between African American and Caucasian participants. A select few baseline differences were found (i.e., African Americans reported higher levels of spirituality than Caucasians; African American participants indicated more perceived benefits of 12-step involvement; Caucasians were more likely to endorse future involvement in 12-step). There were no outcome differences (e.g., substance use outcomes, 12-step meeting attendance). The tested intervention produced similar outcomes for both groups, indicating that it may be useful across racial categories.

Social processes explaining the benefits of Al-Anon participation

This study examined social processes of support, goal direction, provision of role models, and involvement in rewarding activities to explain benefits of participating in Al-Anon, a 12-step mutual-help program for people concerned about another person's substance use. Newcomers to Al-Anon were studied at baseline and 6 months later, at which time they were identified as having either sustained attendance or dropped out. Among both newcomers and established Al-Anon members ("old-timers"), we also used number of Al-Anon meetings attended during follow-up to indicate extent of participation. Social processes significantly mediated newcomers' sustained attendance status versus dropped out and outcomes of Al-Anon in the areas of life context (e.g., better quality of life, better able to handle problems due to the drinker), improved positive symptoms (e.g., higher self-esteem, more hopeful), and decreased negative symptoms (e.g., less abuse, less depressed). Social processes also significantly mediated newcomers' number of meetings attended and outcomes. However, among old-timers, Al-Anon attendance was not associated with outcomes, so the potential mediating role of social processes could not be examined, but social processes were associated with outcomes. Findings add to the growing body of work identifying mechanisms by which 12-step groups are effective, by showing that bonding, goal direction, and access to peers in recovery and rewarding pursuits help to explain associations between sustained Al-Anon participation among newcomers and improvements on key concerns of Al-Anon attendees. Al-Anon is free of charge and widely available, making it a potentially cost-effective public health resource for help alleviating negative consequences of concern about another's addiction.

Toward enhancing 12-step facilitation among young people: a systematic qualitative investigation of young adults' 12-step experiences

BACKGROUND

12-Step Facilitation (TSF) interventions designed to enhance rates of engagement with 12-step mutual-help organizations (MHOs) have shown efficacy among adults, but research provides little guidance on how to adapt TSF strategies for young people.

METHODS

To inform TSF strategies for youth, this study used qualitative methods to investigate the self-reported experiences of 12-step participation, and reasons for nonattendance and discontinuation among young adults (18-24 years; N = 302). Responses to open-ended questions following residential treatment were coded into rationally derived domains.

RESULTS

Young adults reported that cohesiveness, belonging, and instillation of hope were the most helpful aspects of attending 12-step groups; meeting structure and having to motivate oneself to attend meetings were the most common aspects young adults liked least; logistical barriers and low recovery motivation and interest were the most common reasons for discontinued attendance; and perceptions that one did not have a problem or needed treatment were cited most often as reasons for never attending.

CONCLUSIONS

Findings may inform and enhance strategies intended to engage young people with community-based recovery-focused 12-step MHOs and ultimately improve recovery outcomes.

The Molecular Neurobiology of Twelve Steps Program & Fellowship: Connecting the Dots for Recovery

There are some who suggest that alcoholism and drug abuse are not diseases at all and that they are not consequences of a brain disorder as espoused recently by the American Society of Addiction Medicine (ASAM). Some would argue that addicts can quit on their own and moderate their alcohol and drug intake. When they present to a treatment program or enter the 12 Step Program & Fellowship, many addicts finally achieve complete abstinence. However, when controlled drinking fails, there may be successful alternatives that fit particular groups of individuals. In this expert opinion, we attempt to identify personal differences in recovery, by clarifying the molecular neurobiological basis of each step of the 12 Step Program. We explore the impact that the molecular neurobiological basis of the 12 steps can have on Reward Deficiency Syndrome (RDS) despite addiction risk gene polymorphisms. This exploration has already been accomplished in part by Blum and others in a 2013 Springer Neuroscience Brief. The purpose of this expert opinion is to briefly, outline the molecular neurobiological and genetic links, especially as they relate to the role of epigenetic changes that are possible in individuals who regularly attend AA meetings. It begs the question as to whether "12 steps programs and fellowship" does induce neuroplasticity and continued dopamine D2 receptor proliferation despite carrying hypodopaminergic type polymorphisms such as DRD2 A1 allele. "Like-minded" doctors of ASAM are cognizant that patients in treatment without the "psycho-social-spiritual trio," may not be obtaining the important benefits afforded by adopting 12-step doctrines. Are we better off with coupling medical assisted treatment (MAT) that favors combining dopamine agonist modalities (DAM) as possible histone-deacetylase activators with the 12 steps followed by a program that embraces either one or the other? While there are many unanswered questions, at least we have reached a time when "science meets recovery," and in doing so, can further redeem joy in recovery.

Engagement and disengagement in mutual-help addiction recovery housing: a test of affective events theory

This study tested an affective events theory (AET) model in the Oxford House network of recovery homes. Residents' congruence with their home (P-E fit) was hypothesized to directly influence behavior that supported the house and other residents-citizenship behavior. We further hypothesized P-E fit would be related to member intentions to leave, with attitudes toward the home mediating that relationship. To assess this, we administered a cross-sectional national survey to 296 residents of 83 randomly selected Oxford Houses. Although the AET model demonstrated good fit with the data, an alternative model fit better. This alternative model suggested an additional indirect relationship between P-E fit and citizenship mediated by attitudes. Results suggested affective experiences such as feeling like one fits with a community may influence engagement and disengagement. There appears to be a direct influence of fit on citizenship behavior and an indirect influence of fit through recovery home attitudes on both citizenship and intentions to leave the home. We conclude affective experiences could be important for community engagement and disengagement but AET may need to integrate cognitive dissonance theory.

Drug and alcohol addiction: do psychosocial treatments work?

Methodological issues such as social desirability bias, subjective outcome measures, therapist enthusiasm and fidelity to the intervention remain a major problem in assessing the effectiveness of psychosocial treatments for substance misuse. Alcoholics Anonymous and other 12-step programmes are still widely used, although it is difficult to formally assess their effectiveness. Motivational interviewing is perhaps the most commonly used professional psychosocial treatment for substance misuse, but brief interventions based on this technique report a disappointing effect size (∼0.2). Contingency management is perhaps the most effective reported modality, although it remains politically controversial. Cognitive—behavioural therapy and community reinforcement have been widely studied, but the results are often disappointing (effect sizes seldom exceed 0.5, despite very large trials). Residential rehabilitation remains an established treatment, but patient selection prevents formal cost-effectiveness studies.

Is level of exposure to a 12-step facilitation therapy associated with treatment outcome?

This study examined whether level of exposure to Stimulant Abuser Groups to Engage in 12-Step (STAGE-12), a 12-Step facilitative therapy, is related to treatment outcome. Data were from a large National Drug Abuse Treatment Clinical Trials Network (CTN) study comparing STAGE-12 combined with treatment-as-usual (TAU) to TAU alone. These analyses include only those randomized to STAGE-12 (n=234). Assessments occurred at baseline and 30, 60, 90, and 180 days following randomization. High-exposure patients (n=158; attended at least 2 of 3 individual, and 3 of 5 group, sessions), compared to those with less exposure (n=76), demonstrated: (1) higher odds of self-reported abstinence from, and lower rates of, stimulant and non-stimulant drug use; (2) lower probabilities of stimulant-positive urines; (3) more days of attending and lower odds of not attending 12-Step meetings; (4) greater likelihood of reporting no drug problems; (5) more days of duties at meetings; and (6) more types of 12-Step activities. Many of these differences declined over time, but several were still significant by the last follow-up. Treatment and research implications are discussed.

The relationship of therapeutic alliance and treatment delivery fidelity with treatment retention in a multisite trial of twelve-step facilitation

This study examined associations of therapeutic alliance and treatment delivery fidelity with treatment retention in Stimulant Abusers to Engage in Twelve-Step (STAGE-12), a community-based trial of 12-Step Facilitation (TSF) conducted within the National Drug Abuse Treatment Clinical Trials Network (CTN). The STAGE-12 trial randomized 234 stimulant abusers enrolled in 10 outpatient drug treatment programs to an eight-session, group and individual TSF intervention. During the study, TSF participants rated therapeutic alliance using the Helping Alliance questionnaire-II. After the study, independent raters evaluated treatment delivery fidelity of all TSF sessions on adherence, competence, and therapist empathy. Poisson regression modeling examined relationships of treatment delivery fidelity and therapeutic alliance with treatment retention (measured by number of sessions attended) for 174 participants with complete fidelity and alliance data. Therapeutic alliance (p = .005) and therapist competence (p = .010) were significantly associated with better treatment retention. Therapist adherence was associated with poorer retention in a nonsignificant trend (p = .061). In conclusion, stronger therapeutic alliance and higher therapist competence in the delivery of a TSF intervention were associated with better treatment retention whereas treatment adherence was not. Training and fidelity monitoring of TSF should focus on general therapist skills and therapeutic alliance development to maximize treatment retention. (PsycINFO Database Record

Treatment outcomes for prescription drug misusers: the negative effect of geographic discordance

This is the first known study to examine geographic discordance (traveling from one's home residence to a county with a different socio-cultural context to receive substance abuse treatment) as a predictor of clinical and social functioning treatment outcomes (i.e., relapse, self-help attendance, anxiety, and incarceration) among a sample of prescription drug misusers. Treatment entry and 12-month follow-up client-level survey data were collected from 187 clients who misused prescription drugs, and center-level survey data were collected from the supervisors at treatment centers attended by the clients. Multivariate models reveal that geographic discordance significantly increased the odds that prescription drug misusers would report relapse to prescription opioid misuse, anxiety, and any incarceration at follow-up. Moreover, geographically discordant clients were significantly less likely to have attended a self-help group, net of the effect of other individual- and center-level factors. Implications for clinical practice and substance abuse treatment policy are provided.