Alcoholics anonymous affiliation at treatment intake among white and black Americans

Prevalence and correlates of 12-step and second-wave mutual-help attendance in a nationally representative US sample

BACKGROUND

Mutual-help organizations (MHOs) are effective community-based, recovery support options for individuals with alcohol and other drug use disorders (i.e., substance use disorder; SUD). Greater understanding of second-wave MHOs, such as SMART Recovery, can help build on existing research that has focused primarily on 12-step MHOs, such as Alcoholics Anonymous, to inform scientific, practice, and policy recommendations.

METHODS

We conducted a secondary analysis of the National Recovery Study, a representative sample of US adults who resolved a substance use problem (N = 1984). Using survey-weighted estimates, we examined descriptive statistics for any lifetime, weekly lifetime, and past 90-day MHO attendance; we compared rates of 12-step and second-wave MHO attendance over time by descriptively examining distributions for calendar year of the first meeting attended. We also used two logistic regression models to examine demographic, substance use, clinical, and recovery-related correlates of weekly lifetime attendance separately for 12-step (n = 692) and second-wave MHOs (n = 32).

RESULTS

For any attendance, 41.4% attended a 12-step MHO and 2.9% a second-wave MHO; for weekly attendance, 31.9% attended a 12-step MHO, and 1.7% a second-wave MHO. Two-thirds (64%) of initial second-wave attendance occurred between 2006 and 2017 compared to 22% of initial 12-step attendance during this time frame. Significant correlates of weekly 12-step MHO attendance included histories of SUD treatment and arrest. Significant correlates of weekly second-wave MHO attendance included Black identity (vs. White) and history of SUD medication.

CONCLUSIONS

Attendance at second-wave MHOs is far less common than 12-step MHOs, but appears to be on the rise. Observed correlates of second-wave MHO attendance should be replicated in larger second-wave MHO samples before integrating these findings into best practices. Enhanced linkages from clinical and criminal justice settings to both second-wave and 12-step groups may help to "broaden the base" of MHOs.

Mutual-help group participation for substance use problems in the US: Correlates and trends from 2002 to 2018

BACKGROUND

Mutual-help groups (MHGs) are an integral component of the substance use disorder (SUD) treatment system in the U.S., and growing evidence suggests that they are effective and cost-effective for SUD-related problems. However, not much is known about the MHG participation patterns in the U.S.

METHODS

Using the 2002-2018 National Survey on Drug Use and Health data, we estimated the annual participation rates and examined the psycho-social-behavioral correlates of MHG participation using logistic regression.

RESULTS

There was no significant linear trend of MHG participation in the total US adult population between 2002 and 2018 (AOR = 0.999, 95% CI = 0.991-1.007). Among adults with past-year SUD, 4.8-7.4% of men and 4.4-6.7% of women participated in MHGs. MHG participants were more likely to be middle-aged (vs. young adults), lower education (less than high school, high school, some college vs. college or higher), lower income (annual household income <$20,000, $20,000-39,999 vs. $75,000 + ), be unemployed or not in the labor force (vs. employed), and were less likely to be Black/African American (vs. White American) and have lower English proficiency (speak English not well/not at all vs. very well/well),.

CONCLUSION

MHG participation rates have remained relatively stable over the past two decades. MHGs were utilized more by individuals with lower socioeconomic status indicators and more criminal/legal involvement, possibly due to MHGs' free accessibility. However, research is needed to understand why young adults, Black, and individuals with lower English proficiency are somewhat less likely to attend MHGs.

The impact of self-help groups on successful substance use treatment completion for opioid use: An intersectional analysis of race/ethnicity and sex

INTRODUCTION

Race/ethnicity and sex disparities in substance use and substance use treatment completion are well documented in the literature. Previous literature has shown that participation in self-help groups is associated with higher rates of substance use treatment completion. While most of this research has focused on the completion of treatment for alcohol and stimulant use, research examining this relationship using an intersectional approach for individuals in treatment for opioid use is limited.

METHODS

Thus, the current study utilized responses from the Treatment Episodes Data Set-Discharges, 2015-2017 to examine disparities in the relationship between participation in self-help groups and substance use treatment completion for individuals undergoing treatment for opioid use based on sex, race, and ethnicity.

RESULTS

Results revealed a positive association between participation in self-help groups and treatment completion among those in treatment for opioid use across race, ethnicity, and sex. Further, the study found several differences in this association based on one's race, ethnicity, and sex. When compared to men of other races/ethnicities, the association between self-help group participation and treatment completion was highest among Black men.

CONCLUSIONS

The results of the current study extend the knowledge-base about self-help participation's role in promoting successful substance use treatment completion to individuals in treatment for opioid use. Results also highlight the need to examine treatment outcomes with an intersectional lens.

Racial/Ethnic Disparities in Mutual Help Group Participation for Substance Use Problems

Mutual help groups are a ubiquitous component of the substance abuse treatment system in the United States, showing demonstrated effectiveness as a treatment adjunct; so, it is paramount to understand whether they are as appealing to, and as effective for, racial or ethnic minority groups as they are for Whites. Nonetheless, no known comprehensive reviews have examined whether there are racial/ethnic disparities in mutual help group participation. Accordingly, this study comprehensively reviewed the U.S. literature on racial/ethnic disparities in mutual help participation among adults and adolescents with substance use disorder treatment need. The study identified 19 articles comparing mutual help participation across specific racial/ethnic minority groups and Whites, including eight national epidemiological studies and 11 treatment/community studies. Most compared Latinx and/or Black adults to White adults, and all but two analyzed 12-step participation, with others examining "self-help" attendance. Across studies, racial/ethnic comparisons yielded mostly null (N = 17) and mixed (N = 9) effects, though some findings were consistent with a racial/ethnic disparity (N = 6) or minority advantage (N = 3). Findings were weakly suggestive of disparities for Latinx populations (especially immigrants, women, and adolescents) as well as for Black women and adolescents. Overall, data were sparse, inconsistent, and dated, highlighting the need for additional studies in this area.

The Future of Research on Alcohol-Related Disparities Across U.S. Racial/Ethnic Groups: A Plan of Attack

OBJECTIVE

Research suggests striking disparities in alcohol use, problems, and treatment across racial/ethnic groups in the United States. However, research on alcohol-related disparities affecting racial/ethnic minorities remains in its developmental stages. The current article aims to support future research in this growing field by highlighting some of the most important findings, questions, and approaches, focusing on psychosocial research.

METHOD

This article advances seven research needs (i.e., questions and topics meriting attention) that we believe are of crucial importance to the field. We draw on the existing literature to illuminate under-explored areas that are highly relevant to health intervention and that complement the field's existing focus.

RESULTS

Identified research needs include research that (a) better describes disparities in alcohol-related health conditions and their drivers, (b) identifies appropriate screening and brief intervention methods for racial/ethnic minorities, (c) investigates disparities in access to and use of alcohol treatment and support services, (d) examines the comparative efficacy of existing alcohol interventions and develops tailored interventions, (e) explores the impacts of specific alcohol policies across and within racial/ethnic groups, and (f) describes the full spectrum of alcohol-related harms and how and why these may vary across racial/ethnic groups. We also call for (g) continuing research to monitor disparities over time.

CONCLUSIONS

This article points to specific strategies for describing, explaining, intervening on, and monitoring some of the most substantial alcohol-related disparities. Conclusions outline methods and processes that may be advantageous in addressing these priorities, including the use of longitudinal designs; consideration of life course changes; attention to nontraditional intervention settings; and inclusion of disadvantaged populations in all aspects of research.

Ethnic and Gender Differences in Help Seeking for Substance Disorders Among Black Americans

This paper uses the National Survey of American Life (NSAL) to examine within group differences regarding help-seeking for substance disorders among a US sample of African American and Caribbean Black men and women. We examined ethnic and gender differences in the type of providers sought for substance disorder treatment, as well as reasons for avoiding treatment. Results indicate that overall, few ethnic differences exist; however, African Americans are more likely than Caribbean Blacks to seek help from human service professionals (including a religious or spiritual advisor) and from informal sources of treatment such as self-help groups. Black men with a substance disorder were more likely to see a psychiatrist than Black women. Findings regarding reasons for avoiding treatment suggest that there may be a need to provide better education about the utility of substance disorder treatment, even before problems reach a high level of severity.

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.

Preliminary findings on the association between clients' perceived helpfulness of substance abuse treatment and outcomes: does race matter?

BACKGROUND

Few studies examine the helpfulness and effectiveness of substance abuse treatment from the clients' perspective.

METHODS

The current secondary analysis examined the perceived helpfulness of substance abuse treatment components and its relationship to treatment outcomes among 387 Black and White adults participating in a multisite randomized clinical trial (RCT) of Motivational Enhancement Therapy. Throughout the 16-week RCT, participants self-reported substance use. Upon completion of treatment, participants completed a self-report measure assessing the perceived helpfulness of treatment components.

RESULTS

Black participants rated 9 out of 12 treatment components (e.g., "learning skills that will help me cope with my problems") as being more helpful than their White counterparts, even after controlling for age, gender, employment status, primary drug type, and treatment assignment. However, perceived helpfulness ratings were not associated with substance use outcomes among Black or White participants.

CONCLUSIONS

Clients' perceived helpfulness of treatment components is an important factor to consider in improving the delivery of substance abuse treatment, especially for Black adults.

12-step interventions and mutual support programs for substance use disorders: an overview

Social workers and other behavioral health professionals are likely to encounter individuals with substance use disorders in a variety of practice settings outside of specialty treatment. 12-Step mutual support programs represent readily available, no cost community-based resources for such individuals; however, practitioners are often unfamiliar with such programs. The present article provides a brief overview of 12-Step programs, the positive substance use and psychosocial outcomes associated with active 12-Step involvement, and approaches ranging from ones that can be utilized by social workers in any practice setting to those developed for specialty treatment programs to facilitate engagement in 12-Step meetings and recovery activities. The goal is to familiarize social workers with 12-Step approaches so that they are better able to make informed referrals that match clients to mutual support groups that best meet the individual's needs and maximize the likelihood of engagement and positive outcomes.

Interrelationship of substance use and psychological distress over the life course among a cohort of urban African Americans

BACKGROUND

Substance use and psychological problems are major public health issues because of their high prevalence, co-occurrence, clustering in socio-economically disadvantaged groups, and serious consequences. However, their interrelationship over time is not well understood.

METHODS

This study identifies and compares the developmental epidemiology from age 6 to 42 of substance use and psychological distress in a population of African American men and women. Data come from the Woodlawn study, a longitudinal study of an urban community cohort followed since 1966. We use structural equation modeling to examine pathways between substance use (i.e., alcohol, marijuana, and cocaine) and psychological distress over time by gender.

RESULTS

We find significant continuity from adolescence to midlife for substance use and for psychological distress, as well as significant correlations within time periods between substance use and psychological distress, particularly among women. We also find greater adolescent substance use predicts psychological distress in young adulthood for men, but no cross-lag associations for women. Women's adolescent psychological distress and substance use are linked uniquely to that of their mothers. Findings show additional gender differences in the developmental etiology of substance use and psychological distress.

CONCLUSIONS

Findings demonstrate the continuity of substance use and psychological distress over time; the contemporaneous relationships between psychological distress and substance use within time periods, and minimal cross-lagged relationships. Findings also show that adolescent substance use may set boys on a pathway of long-term psychological distress, thus adding to evidence of negative consequences of frequent use.

Does sponsorship improve outcomes above Alcoholics Anonymous attendance? A latent class growth curve analysis

AIMS

To construct Alcoholics Anonymous (AA) attendance, sponsorship and abstinence latent class trajectories to test the added benefit of having a sponsor above the benefits of attendance in predicting abstinence over time.

DESIGN

Prospective with 1-, 3-, 5- and 7-year follow-ups.

SETTING AND PARTICIPANTS

Alcoholic-dependent individuals from two probability samples, one from representative public and private treatment programs and another from the general population (n = 495).

FINDINGS

Individuals in the low attendance class (four classes identified) were less likely than those in the high, descending and medium attendance classes to be in high (versus low) abstinence class (three classes identified). No differences were found between the other attendance classes as related to abstinence class membership. Overall, being in the high sponsor class (three classes identified) predicted better abstinence outcomes than being in either of two other classes (descending and low), independent of attendance class effects. Although declining sponsor involvement was associated with greater likelihood of high abstinence than low sponsor involvement, being in the descending sponsor class also increased the odds of being in the descending abstinence class.

CONCLUSIONS

Any pattern of Alcoholics Anonymous attendance, even if it declines or is never high for a particular 12-month period, is better than little or no attendance in terms of abstinence. Greater initial attendance carries added value. There is a benefit for maintaining a sponsor over time above that found for attendance.

Formal and informal substance use treatment utilization and alcohol abstinence over seven years: is the relationship different for blacks and whites?

BACKGROUND

This study examines whether the effects of formal substance use treatment utilization and Alcoholics Anonymous (AA) on 30-day abstinence vary for black versus white Americans.

METHODS

The current analysis utilizes data from a longitudinal sample of 1013 black and white, dependent and problem drinkers across a 7-year period. Participants were identified through a probability survey in the general population and consecutive intakes in chemical dependency treatment programs in a California County. Generalized Estimating Equations assessing interactions between race and treatment utilization incorporated variables from four post-baseline interviews, controlling for baseline variables.

RESULTS

Formal treatment utilization was associated with 30-day abstinence (OR:1.6, 95%CI: 1.3, 2.1), yet this relationship did not differ for blacks and whites. In contrast, there was a significant interaction between AA utilization, race and 30-day abstinence. While both whites and blacks who attended AA were more likely to report 30-day abstinence compared to their non-AA attending counterparts (white OR:4.0, 95%CI: 3.2-5.1 and black OR:2.2, 95%CI: 1.5-3.2), the relationship was stronger for whites. Among those who did not attend AA, blacks were more likely than whites to be abstinent. Post hoc analyses suggest that these latter findings may be related to greater religiosity and "drier" social networks among black Americans.

CONCLUSIONS

While utilization of formal treatment may yield similar benefits for blacks and whites, AA utilization may be more important for maintaining abstinence among whites than blacks. Future research should investigate racial differences in social network drinking patterns and religious reinforcement of sobriety, and the role these may play in AA outcomes.

Implementation of evidence-based substance use disorder continuing care interventions

Continuing care following initial substance use disorder treatment often is associated with improved treatment outcomes and evidence-based interventions (EBIs) have been developed in this area. However, rates of patient participation in continuing care treatment and mutual help groups (MHGs) are low and a large gap exists between the existing EBIs and actual clinical care. This paper uses the Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009) to review the literature on continuing care treatment and monitoring, and mutual help-group promotion. Although existing research provides implications for implementing EBIs in continuing care, few direct implementation trials have been conducted. This literature indicates that EBIs in continuing care have been successfully modified for different settings, that they can be delivered using different modalities (e.g., individual, group, and telephone-based care), and that low cost options are available. Additionally, much is known about the differential effectiveness of continuing care with different populations that may guide treatment programs and providers in selecting the most effective interventions for their clients. One significant barrier to successful implementation of EBIs for continuing care is the lack of information about incentives for providing continuing care across what in the CFIR terminology is a program's outer setting (i.e., external economic, political, and social setting), and its inner setting (i.e., internal political, structural, and cultural contexts). Implications for implementation of EBIs in substance use disorder continuing care are discussed.

Following problem drinkers over eleven years: understanding changes in alcohol consumption

OBJECTIVE

Much of what we know about the course of alcohol consumption in problem and dependent drinkers comes from studies of in-treatment populations. Less is known about the natural course of alcohol consumption among such drinkers in the general population and what predicts how much they drink.

METHOD

This study examined alcohol consumption over the course of 11 years in a randomly selected sample of 672 problem and dependent drinkers from a single, heterogeneous U.S. county.

RESULTS

Alcohol consumption declined and leveled off over time but did not decrease to the average general U.S. population level. Several indicators of ongoing problems with drinking are associated with high levels of drinking over time: having a heavy-drinking network, receiving suggestions to do something about one's drinking, and going to treatment. Factors associated with less drinking include having contact with community agencies and going to Alcoholics Anonymous (AA).

CONCLUSIONS

Results suggest that problem and dependent drinkers continue to drink at an elevated level over the course of years. Gatekeepers, family members, and policymakers should encourage and facilitate contact with social service agencies and with AA for problem drinkers. Suggestions from others to do something about one's drinking and seeking specialty care occur more often in those with more severe problems and do not appear to be linked to less drinking over time.

Trends in alcohol services utilization from 1991-1992 to 2001-2002: ethnic group differences in the U.S. population

BACKGROUND

During the early 1990s in the United States, changes to the provision and financing of alcohol treatment services included reductions in inpatient treatment services and in private sector spending for treatment. We investigated trends in alcohol services utilization over the 10-year period from 1991-1992 to 2001-2002 among U.S. whites, blacks, and Hispanics.

METHODS

Data come from 2 household surveys of the U.S. adult population. The 1991 to 1992 National Longitudinal Alcohol Epidemiologic Survey and the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions conducted face-to-face interviews with a multistage cluster sample of individuals 18 years of age and older in the continental United States. Treatment utilization represented both total utilization and the use of alcohol services. Data analyses were prevalence rates and multivariate logistic regressions for lifetime utilization with drinkers and individuals with alcohol use disorders (AUDs).

RESULTS

From 1991-1992 to 2001-2002, drinking-related emergency room and human services use increased for drinkers, while total utilization and the use of private health professional services and mutual aid decreased for individuals with AUDs. In drinkers and individuals with AUDs, blacks and Hispanics were less likely than whites to use private health professional care. Hispanics with AUDs were less likely than whites with AUDs to use alcohol or drug programs. Ethnicity interacted with alcohol severity to predict alcohol services utilization. At higher levels of alcohol severity, blacks and Hispanics were less likely than whites to ever use treatment and to use alcohol services (i.e., human services for Hispanic drinkers, mental health services for blacks with AUDs, and mutual aid for Hispanics with AUDs).

CONCLUSIONS

Our findings showed increases from 1991-1992 to 2001-2002 in alcohol services utilization for drinkers, but reductions in utilization for individuals with AUDs. Blacks and Hispanics, particularly those at higher levels of alcohol severity, underutilized treatment services compared to whites. These utilization trends for blacks and Hispanics may reflect underlying disparities in healthcare access for minority groups, and language and logistical barriers to utilizing services.

For the Marginalized or for the Integrated? A Comparative Study of Addiction Treatment Systems in Sweden and the United States

This article compares the roles of two different addiction treatment systems, one in Stockholm county, surrounding the Swedish capital, and the other in a county in Northern California, in relation to marginalized and socially integrated misusers. It investigates: (a) whether the Swedish treatment system, as suspected, treats more marginalized clients than the American system, (b) where in the two systems those with stronger or weaker social ties show up, and (c) what kind of formal and informal pressures the socially marginalized and more integrated groups experience. The analyses are based on structured interviews with two representative samples of clients/patients entering different parts of the treatment systems (926 persons in the Californian county in 1995, 1,865 persons in Stockholm county 2000–2001). The Stockholm county treatment system has a much higher share of marginalized persons than the Californian, and a large proportion in California, almost one third, has both a job and a stable housing (15% in Stockholm). The Stockholm clients were considerably older. Drug use was connected with a marginalized position in both countries, and particularly so in Stockholm. The socially integrated in Stockholm stood out as the group with the highest share of alcohol-dependent persons, the highest Addiction Severity Index (ASI) alcohol scores, and the highest amount of heavy drinking. In both sites, the marginalized had more treatment experience and were more often found in inpatient treatment. There was a somewhat clearer social division in the U.S. system than in the Swedish. Some reasons for this are discussed, including the relation of the treatment system to other handling systems.

Using propensity scores to adjust for selection bias when assessing the effectiveness of Alcoholics Anonymous in observational studies

BACKGROUND

The effectiveness of Alcoholics Anonymous (AA) is difficult to establish. Observational studies consistently find strong dose-response relationships between AA meeting attendance and abstinence, and the only experimental studies favoring AA have been of 12-step facilitation treatment rather than of AA per se. Pending future randomized trials, this paper uses propensity score (PS) method to address the selection bias that potentially confounds the effect of AA in observational studies.

METHOD

The study followed a treatment sample for 1 year to assess post-treatment AA attendance and abstinence (n=569). Propensity scores were constructed based on known confounders including motivation, problem severity, and prior help-seeking. AA attendance during the 12-month follow-up period was studied as a predictor of alcohol abstinence for 30 days prior to the follow-up interview. PS stratification and PS matching techniques were used to adjust for the self-select bias associated with respondents' propensity to attend AA.

RESULTS

The overall advantage in abstinence initially observed narrowed when adjusted. The odds ratio associated with AA attendance reduced from 3.6 to 3.0 after PS stratification and 2.6 after PS matching to AA-attenders. Support for AA effectiveness was strengthened in the quintile with lower propensity scores and when AA-nonattenders were matched as the target group, but was weakened among those in the higher PS quintiles and when matching to AA-attenders.

DISCUSSION

These results confirm the robustness of AA effectiveness overall, because the results for higher abstinence associated with AA attendance following propensity score adjustment remained significant, and the reduction in the magnitude of AA's effect was moderate. However, the effect modification by propensity scores in both PS stratification and PS matching approaches seems to suggest that AA may be most helpful, or matter more, for those with a lower propensity to attend AA. Conversely, for those with a high propensity to go to AA (operationalized as higher motivation, greater problem severity, more prior AA and treatment exposure, etc.), attending AA may not make as much of a difference. It will be important that future studies replicate our results, as this is the first paper to use propensity score adjustment in this context.

Spirituality during alcoholism treatment and continuous abstinence for one year

OBJECTIVE

The primary aim of this prospective study was to examine the role of several aspects of spirituality in maintaining abstinence from alcohol for one year in persons treated for alcohol dependence. The roles of alcohol abstinence self-efficacy and Alcoholics Anonymous affiliation were also examined.

METHOD

Seventy-four adults with alcohol dependence who had completed a three-week outpatient addiction program participated in this study. Instruments used included the Spiritual Well-Being Scale, Duke Religion Index, Brief Religious Coping Scale, Alcohol Abstinence Self-Efficacy Scale, and Alcoholics Anonymous Affiliation Scale. Abstinence data was collected from participants and collaterals three, six, and twelve months after treatment discharge. Demographics, discharge measures, and the change in scores from admission to discharge were compared between those with and without 12-month alcohol abstinence using logistic regression or Fisher's exact tests.

RESULTS

Twenty-eight participants were categorized as continuously abstinent for one year. The strongest associations between 12 month abstinence and the variables of interest were discharge scores of abstinence self-efficacy and existential well-being, and increases during treatment in scores of private spiritual practices. Increased age demonstrated a significant association with positive outcome.

CONCLUSION

The associations of private spiritual practices, existential well-being, and abstinence self-efficacy with one year of continuous abstinence following treatment discharge suggest the importance of addressing issues related to these variables during alcoholism treatment. More research is needed to understand the role of these variables in promoting and maintaining abstinence and to determine whether or not a related intervention would improve abstinence rates.

Concerns about dose and underutilization of twelve-step programs: models, scales, and theory that inform treatment planning

Researchers have observed that a majority of addicted persons who are encouraged and facilitated by treatment providers to attend twelve-step (TS) programs either drop out or sporadically use twelve-step programs following treatment. This is troubling given considerable evidence of TS program benefits associated with regular weekly attendance and ubiquitous reliance by treatment professionals on these programs to provide important support services. This chapter reviews and advances theory of TS utilization and dose that is supported by prior research, multivariate models, and scales that predict risk of TS meeting underutilization. Advancing theory should organize and clarify the process of initial utilization, guide intervention development, and improve adherence of TS program referrals, all of which should lead to improved treatment planning and better outcomes. Three theories are integrated to explain processes that may influence TS program dose: the health belief model, self-determination theory (motivational theory), and a person-in-organization cultural fit theory. Four multidimensional scales developed specifically to predict participation are described. Implications for practice and future research are considered in a final discussion. Information contained in this chapter raises awareness of the need for TS-focused treatments to focus on achieving weekly attendance during and after treatment.

Predictors of engagement in continuing care following residential substance use disorder treatment

BACKGROUND

Patients in intensive SUD programs who subsequently participate in continuing care for a longer interval have better outcomes than those who participate for a shorter interval. We sought to identify patient and program factors associated with duration of engagement in SUD continuing care after residential/inpatient treatment.

METHODS

Patients (n=3032) at 15 geographically diverse SUD residential treatment programs provided data on demographics, symptom patterns, recovery resources, and perceptions of treatment environment. We identified patient characteristics associated with the number of consecutive months of engagement in continuing care. We then consolidated and classified risk factors into an integrated model.

RESULTS

Being African American, having more SUD and psychiatric symptoms, more resources for recovery, and perceiving the treatment staff as being supportive were associated with longer engagement in continuing care. African Americans' engagement in continuing care was 17% longer than Caucasians'. The positive effect of being African American was partially mediated by having taken actions toward changing use, and by the presence of psychotic symptoms.

CONCLUSION

These results extend previous research on the predictors of continuing care engagement after residential SUD programs. Clinicians can use information about characteristics that put patients at risk for shorter engagement in continuing care to target patients who might benefit from interventions to increase engagement in continuing care.

Need and non-need factors associated with addiction treatment utilization in a cohort of homeless and housed urban poor

BACKGROUND

Research on addiction treatment utilization in indigent samples mainly has been retrospective, without measures of addictive consequences, social network influences, and motivation. Prospective assessment of factors influencing utilization could inform policy and clinical care.

OBJECTIVE

We sought to identify factors associated with utilization of addiction treatment and mutual help groups among substance-dependent persons with high rates of homelessness.

RESEARCH AND METHODS

This was a prospective cohort of patients detoxified from alcohol or drugs at baseline who were followed for 2 years in a randomized clinical trial of linkage to primary care (n = 274). Outcomes included utilization of Inpatient/Residential, Outpatient, Any Treatment, and Mutual Help Groups. Predictor variables in longitudinal regression analyses came from the literature and clinical experience, organized according to theoretical categories of Need, and non-Need (eg, Predisposing and Enabling).

RESULTS

Many subjects used Inpatient/Residential (72%), Outpatient (62%), Any Treatment (88%) or Mutual Help Groups (93%) at least once. In multivariable analyses, addictive consequences (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.12-1.71), motivation (OR 1.32, 95% CI 1.09-1.60), and female gender (OR 1.80, 95% CI 1.13-2.86) were associated with most treatment types (ORs are for Any Treatment). Homelessness was associated with Residential/Inpatient (for Chronically Homeless vs. Housed, OR 1.75, 95% CI 1.04-2.94). Living with one's children (OR 0.51, 95% CI 0.31-0.84) and substance-abusing social environment (OR 0.65, 95% CI 0.43-0.98) were negatively associated with Any Treatment.

CONCLUSIONS

In this cohort of substance-dependent persons, addictive consequences, social network variables, and motivation were associated with treatment utilization. Non-need factors, including living with one's children and gender, also were significant.

Does diagnosis matter? Differential effects of 12-step participation and social networks on abstinence

Previous studies that have examined the effects of specific aspects of 12-step participation and social network composition on abstinence have focused mostly on alcohol-related outcomes and have screened out drug dependent persons. This article explores whether these predictors differentially affect abstinence based on DSM-III-R substance dependence disorder (alcohol dependence, drug dependence, and both alcohol and drug dependence). A heterogeneous community sample of treatment seekers (N=302) randomized to day treatment programs were followed at 6 and 12 months. Bivariate and multivariate regression models were used to test whether engagement in 12-step practices and social network influences to drink or use drugs predicted total abstinence from alcohol and drugs differentially by dependence disorder. Chi-square automatic interaction detector (CHAID) segmentation analyses were then conducted to identify the specific 12-step activities and social network thresholds that best distinguished higher rates of abstinence in each dependence category. Results showed that the number of 12-step meetings attended and number of prescribed 12-step activities engaged in similarly predicted abstinence for alcoholics, drug addicts, and those dependent on both alcohol and drugs. However, specific activities were associated with abstinence differentially by dependence disorder. While many activities differentiated abstinence for drug addicts and those dependent on both alcohol and drugs, for alcoholics only two Alcoholics Anonymous (AA) activities distinguished abstinence (having a sponsor and doing service). Key predictors of abstinence (CHAID) varied by follow-up and dependence disorder, except for doing service in AA and/or Narcotics Anonymous, which was the only specific 12-step activity that was a best predictor of abstinence in all three categories one year following treatment. Thus, "giving back" to one's peer community through service work, an important 12-step belief, seems to be universally valuable later in recovery. As for social network influences, a multivariate regression model showed that having a higher proportion of abstinent individuals in the network was associated with abstinence for alcoholics at 6 months only and for drug dependent persons at 12 months only. CHAID models supported these results and provided specific thresholds for 12-step measures (e.g., >20 meetings for alcoholics, 2 or more nondrinkers in the social network, 3 or more persons supporting reduction for those dependent on both alcohol and drugs, and having 2 or more nondrinkers for those dependent on drugs only). These results support the value of treatment providers prioritizing certain 12-step-related practices and social network changes based on their client dependence profiles. Early on, those with an alcohol diagnosis need to make a commitment to meetings and obtain a sponsor; also, they need to place themselves in a network that encourages sobriety. Early on, those who are drug-dependent-only especially need to become connected with 12-step programs to the extent that they consider themselves a member, and, later, saturate themselves in a highly supportive and predominantly nondrinking environment. Alcohol and drug dependent clients need more intense ongoing 12-step involvement (sponsor and meetings) as well as having nondrinking individuals and people supportive of abstinence in their network. For all clients, doing service is especially important at the longer 12-month posttreatment timeframe.

Cirrhosis mortality in Ontario: effects of alcohol consumption and Alcoholics Anonymous participation

AIMS

We test the hypotheses that cirrhosis mortality rates are positively associated with per capita alcohol consumption and negatively associated with Alcoholics Anonymous (AA) membership rates.

DESIGN

The impact of alcohol consumption levels and AA membership rates on cirrhosis mortality rates in Ontario from 1968 to 1989 were examined. Time-series analyses with ARIMA modelling were applied to male and female cirrhosis mortality rates in three age groups: 15-44, 45-64 and 65 + years. Missing AA membership data were interpolated using two methods: linear splines and cubic splines.

FINDINGS

In general, cirrhosis mortality rates were positively associated with alcohol consumption and negatively associated with AA membership. For some age and gender combinations, these effects were not statistically significant.

CONCLUSIONS

The limits of this study include restrictions in the length of series available and in the ability to infer causality. Despite these limitations, these findings are consistent with previous research demonstrating that per capita consumption is a strong determinant of cirrhosis mortality rates, and also that higher levels of AA membership can reduce cirrhosis mortality rates.

Race, Managed Care, And The Quality Of Substance Abuse Treatment

The adoption of managed behavioral health care by state Medicaid agencies has the potential to increase the quality of treatment for racial minorities by promoting access to substance abuse treatment and creating more appropriate utilization patterns. This paper examines three indicators of quality for white, Black, and Hispanic Medicaid clients who received substance abuse treatment in Massachusetts between 1992 and 1996. It evaluates whether a managed behavioral health care carve-out in FY1993 had a positive or negative effect on access, continuity of care, and 30-day re-admissions. Prior to managed care, access and continuity were worse for minorities than for whites. For all clients under managed care, access and continuity improved between 1992 and 1996. Access improved more for Hispanic clients relative to other racial groups. Continuity improved more for Black clients relative to other racial groups. Although seven-day and 30-day re-admissions also increased following managed care, the rate of increase was not significantly greater for minorities. Although managed care had a beneficial impact on the quality of treatment for minority clients, the percent of minority Medicaid-eligible clients who accessed treatment and the percent who achieved continuity of care remained lower than for whites in every year of the study. Managed care reduced, but did not overcome, racial disparities in behavioral health care.

Predictors of retention in dual-focus self-help groups

Attendance at 12-step groups has been found useful in maintaining abstinence from substance use; many members disengage early, missing out on potential benefits. New 12-step based groups have emerged to address the recovery needs of the many substance users with psychiatric comorbidity. Little is known about factors associated with retention in 12-step, especially in this population. This study sought to identify predictors of retention over a one-year period among members of a dual-focus 12-Step fellowship (N = 276). Using multivariate analysis, the following baseline characteristics were associated with greater retention one year later: older age, more lifetime arrests, abstinence in the pre-baseline year, more psychiatric symptoms in the pre-baseline year, not taking psychiatric medication, being more troubled by substance abuse than by mental health, and greater level of self-efficacy for recovery; residing in supported housing and being enrolled in outpatient treatment at follow-up were also significantly associated with better retention. Clinical implications to enhance retention in specialized 12-step groups are discussed.

Participation in 12-Step-Based Fellowships Among Dually-Diagnosed Persons

Twelve-step groups (12SG), a useful recovery resource, are underutilized by dually-diagnosed persons. There has been little empirical research in this area. This study followed members of a dual-focus 12-step-based fellowship (N = 277) over one year to gain a greater understanding of participation in both specialized dual focus and traditional 12SG among dually-diagnosed persons, including reasons for attending, perceived benefits of and obstacles to affiliation, and predictors of affiliation. Findings indicate that dually-diagnosed persons do engage in both types of fellowships; patterns of engagement differed across fellowships, suggesting different comfort levels. Both types of fellowships were used to deal with addiction. Greater difficulty with substance use at baseline was associated with greater likelihood of attending 12SG at follow-up; the reverse was true for self-reported substance use at baseline. Findings are discussed in light of existing literature and clinical implications are suggested.