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Alcoholics Anonymous and other 12-step programmes for alcohol dependence
Abstract
As well as AA, there are also alternative interventions based on 12-step type programmes, some self-help and some professionally-led. AA and other 12-step approaches are typically based on the assumption that substance dependence is a spiritual and a medical disease. The available experimental studies did not demonstrate the effectiveness of AA or other 12-step approaches in reducing alcohol use and achieving abstinence compared with other treatments, but there were some limitations with these studies. Furthermore, many different interventions were often compared in the same study and too many hypotheses were tested at the same time to identify factors which determine treatment success.
... Validität des primären Outcomes "kontinuierliche Abstinenz" Stanton Peele [5] wies bereits in einer ersten Replik kurz nach Erscheinen des Reviews darauf hin, dass die maßgebliche Neuerung gegenüber der 2006 erschienene Cochrane-Analyse zu 12 Schritte Programmen [7] auf einem Wechsel der zentralen Outcome-Parameter beruht. Entgegen der früheren Version wurde nicht mehr klinisch signifikante Verbesserung, sondern anhaltende Abstinenz zum Schlüsselkriterium erhoben. ...
... B. auch der Einsatz von Motivational Interviewing zur Förderung der Motivation, eine Selbsthilfegruppe zu besuchen [13]. Zudem wurde mehrheitlich in den Studien nicht ein ausschließliches 12-Schritte-Programm gegen andere theoretische Orientierungen geprüft, sondern die analysierten Studien weisen eine deutliche Heterogenität sowohl hinsichtlich der eingesetzten "TSF-Programme" als auch hinsichtlich der herangezogenen Kontrollbedingungen auf -in dem ersten Cochrane-Review wurde darauf hingewiesen, dass die geprüften TSF-Konzepte mehrheitlich Kombinationen mit anderen psychosozialen Interventionen darstellen [7], ohne dass diese Limitation bei der überarbeiteten Version expliziert wurde, wenngleich die Art der geprüften TSF-Interventionen unverändert blieb. ...
Zusammenfassung
Eine 2020 veröffentlichte, aktualisierte Cochrane-Analyse zu Anonymen Alkoholikern und 12-Schritte Programmen zur Behandlung alkoholbezogener Störungen schreibt diesen Interventionsformen eine bessere Evidenz gegenüber etablierten psychotherapeutischen Verfahren zu. Der Beitrag stellt zentrale Befunde des Reviews vor und überprüft deren interne und externe Validität. Diese sind eingeschränkt durch die verwendeten Definitionen der Outcomeparameter, der Interventions- und Kontrollbedingungen, die Selektivität der berichteten Ergebnisse und die eingeschränkte Generalisierbarkeit der Stichproben.
... These were: (a) internal and external validity of our review, (b) whether our 2020 Cochrane review is an advancement over the 2006 Cochrane review on AA/TSF (i.e. Ferri et al., 2006) and (c) how applicable the results are in countries other than the USA. Heather (2020) argues that the finding that AA/TSF produced considerably higher rates of continuous abstinence compared with other treatments, such as CBTs, at the 12-month follow-up timepoint did not correspond with similar advantages in measures of percent days abstinent (PDA), drinking intensity (i.e. ...
... Heather (2020) also questions whether the new review is in fact 'an advance on previous findings' over the previous 2006 review (Ferri et al., 2006), because the new review 'rested on different outcome measures'. Again we are puzzled, because every outcome in the original review was included in the new review (Kelly et al., 2020b). ...
... Even though respondents to this survey with a personal history of psychedelic use expressed more supportive views, results suggest that this sample of peer recovery coaches are concerned about the potential harms, the addictive potential of psychedelics, and remain skeptical that 12-step members would be supportive. These findings are consistent with the literature on 12-step programs and its model of an abstinence-focused approach to recovery, as well as with prior reports that suggest personal history has a strong influence on current attitudes and beliefs [19,20]. That most (76%) of the responding peer recovery coaches reported prior experience with psychedelics is notable, and further research is warranted to determine whether this prevalence is representative of peer recovery coaches in general. ...
Background
There has been a growing interest in the use of psychedelics for therapeutic purposes. However, there is a lack of research on peer recovery coaches' attitudes toward the use of psychedelics for SUD treatment. Therefore, we conducted a survey of peer recovery coaches in Massachusetts to gain insight into their attitudes toward the use of psychedelics to treat SUDs.
Methods
Peer recovery coaches in Massachusetts were invited to participate in an online survey between August and October 2023. The survey collected respondents’ demographics, socioeconomic characteristics, personal substance use history, opinions on psychedelics for addiction treatment, and spiritual experiences.
Results
146 individuals completed the survey. The mean age was 48.7 years (SD 11.2), 61% identified as female, 74% were employed as peer recovery coaches, and 43% were Certified Addiction Recovery Coaches (CARC). 70.7% reported utilizing 12-step programs, and 76% reported having a personal history of using psychedelics. The majority of participants agreed that they would feel comfortable being a coach for someone using psychedelics to treat SUDs. However, a significant number of participants expressed concerns. Those who had utilized 12-steps were more likely to express concerns about the dangers of using psychedelics to treat SUD. Conversely, participants with a personal history of psychedelic use were more likely to support the use of psychedelics for the treatment of SUDs.
Conclusions
While peer recovery coaches express support for using psychedelics to treat SUD, they also voice concerns about the potential risks.
... Both approaches are heading to constant development, along which there are multiple possible alternatives to follow. These alternatives include psychological and pharmacological supports, self-aid such as Alcoholics Anonymous offering emotional support and helping to reinforce the motivation and Rational Recovery groups focused on regaining the selfconfidence [27,28]. The motivational support showed that the most effective cure is aiming to reduce the alcohol intake [29]. ...
Introduction
The WHO European Mental Health Action Plan (2013–2030) emphasises the need to generate services that are more inclusive and attentive to the co‐construction of care practices. This exploratory research investigates the needs of young substance abusers shown during their stay in residential communities; in particular, it explores the idea that treatment may include a new phase focused on how to manage moderate or controlled alcohol intake during residential care. Interviews with young ex‐users open up critical reflections on complete abstinence programmes from all substances, including alcohol, as a prerequisite for discharge and also provide examples of how to co‐design a plan for mindful drinking.
Methods
Fourteen young adults, aged 19–32 years, non‐alcoholists, treated at rehab in Fermo, in central Italy, were interviewed during a programme between 6 and 18 months of period. They were asked about exploring needs in preparation for the conclusion of the rehabilitation pathway. From this exploration emerged the need to introduce controlled alcohol intake during the rehabilitation stay. This request became the focus of the semi‐structured interviews.
Results
Three main themes emerged, which are as follows: (1) difficulties in integrating the new identity with the past of consumption, (2) resistance to the idea of total abstinence in social relations and (3) uncertainties about post‐community behaviour regarding alcohol intake. At the same time, three unexpected needs were expressed: (1) test the personal knowledge and skills on how to manage the alcohol intake, (2) receive support during the residential path to build up self‐control competence given the post‐discharge period and (3) build a personalised therapeutic path together with the supervisor and the operators while still at the rehab, according to the realistic lifestyle and routine outside the rehab.
Conclusions
This research highlights the importance of personalising treatment based on each user's needs, going far beyond the standardised treatments for users previously considered unable of self‐control and self‐determination. For that purpose, the relationship between the users and the operators might be privileged, as it is able to cover the specific needs aimed for the new identity.
Involving the Participants
The research sparked a discussion within the community, involving and initiating an open dialogue between the operators and the users, allowing them to focus on certain innovative strategies offered by the service, putting the users' needs at the very centre of the attention. The results were compared and discussed actively with the participants involved.
... AA is a worldwide peer-to-peer support group with a 12-step program (Kelly et al., 2020). There is mixed evidence about the effectiveness of AA (Kaskutas, 2009): Some studies indicate that it is related to worse outcomes than no treatment (Kownacki & Shadish, 1999), others show that it has no empirical effectiveness (Ferri et al., 2006), and still others find that it is causally associated with abstinence (Humphreys et al., 2014). The most recent systematic reviews and meta-analyses generally support a positive association between participation in AA and abstinence (e.g., Adriana & Wicaksono, 2023;Kelly et al., 2020). ...
Background
Alcohol use disorder (AUD) is a highly impairing condition with important public health impacts. Despite the availability of treatment options for AUD, research shows that few people receive treatment, and even fewer can maintain abstinence/low‐drinking levels. This study investigated the role of personality traits in past‐year alcohol use among individuals with severe AUD who ever attended Alcoholics Anonymous (AA), a widespread and easily accessible self‐help group for alcohol problems.
Methods
Univariable and multivariable regressions were performed separately in females and males with alcohol consumption as an outcome. Socioeconomic factors, genetic liability, and psychopathology were included as covariates in the analyses.
Results
Results from the multivariable model indicated that in females who attended AA, greater alcohol use was related to both positive and negative urgency and low sensation seeking, while in males, greater alcohol use was related to positive urgency. Results also showed that, in both sexes, younger age and lower educational levels were associated with greater alcohol use. Moreover, single males and individuals with lower AUD severity were at higher risk of using alcohol in the past year.
Conclusions
These findings highlight sex‐specific correlates of drinking in individuals with AUD who engaged in self‐help groups. These findings may help to improve treatment options, as personality encompasses modifiable traits that can be targeted in psychological interventions.
... Some of the reasons for this include their widespread availability and easy local accessibility (including increasingly online), as well as their flexibility and low or no cost to participants (Humphreys, 2004;Kelly & Yeterian, 2008Kelly, 2022). Empirical evidence is also strong regarding the clinical and public health utility, effectiveness, and cost-effectiveness of some of these organizations, particularly the largest and oldest -Alcoholics Anonymous (AA, 1952;Ferri et al., 2006;Humphreys et al., 2020;Kelly et al., 2020), and evidence is beginning to emerge also regarding the utility of others (e.g., Zemore et al., 2017Zemore et al., , 2018. Consequently, due to the enormous burden of disease, disability, and premature mortality attributable to alcohol and other drug use disorders each year (Degenhardt et al., 2018), the widespread availability, effectiveness, and costeffectiveness of these ubiquitous and growing entities have been described as the closest public health has to a "free lunch" (Kelly, 2017a). ...
... Formats of psychotherapy delivery include individualized or group, in person, videoconferencing, or telephone. First-line, guideline-recommended psychotherapy modalities that appear in these psychiatric treatment guidelines, as summarized in Table 2, are CBT (28), contingency management (29), dialectical behavior therapy (DBT) (30), eye movement desensitization and reprocessing (EMDR) (31), family therapy (24,32), interpersonal psychotherapy (IPT) (33), MBT (34), motivational interviewing (MI) (35), peer support (36), problem-solving therapy (PST) (37), short-term psychodynamic psychotherapy (38), psychoeducation (39), and 12-step facilitation (40). An additional noteworthy psychotherapy that is not included in Tables 1 or 2 or the online supplement is the integrative Maudsley model of anorexia nervosa treatment for adults (MANTRA). ...
Clinical decision making by psychiatrists and informed consent by patients require knowledge of evidence-based psychotherapies (EBPs) and their indications. However, many mental health professionals are not versed in the empirical literature on EBPs or the consensus guideline recommendations derived from this literature. The authors compared rigorous national consensus guidelines for EBP treatment of DSM-defined adult psychiatric disorders-derived from well-conducted randomized controlled trials and meta-analyses and from expert opinions from the United States, United Kingdom, and Canada-to create the Psychotherapies-at-a-Glance tool. Recommended EBPs are cognitive-behavioral therapy, family therapy, contingency management, dialectical behavior therapy, eye movement desensitization reprocessing, interpersonal psychotherapy, mentalization-based treatment, motivational interviewing, peer support, problem-solving therapy, psychoeducation, short-term psychodynamic psychotherapy, and 12-step facilitation. The Psychotherapies-at-a-Glance tool summarizes the indications, rationales, and therapeutic tasks that characterize these differing psychotherapies and psychosocial treatments. The tool is intended for use in clinical teaching, treatment planning, and patient communications.
... Furthermore, the relative efficacy of DHIs in comparison to treatment-as-usual or active control groups suggests that DHIs could be effective interventions for ASD. 57 It is controversial whether age and IQ could influence the effect of DHI treatment in ASD patients. Different from previous studies, 16,54,58 age groups were significantly associated with the intervention effect. ...
Importance
Digital technology is now widely available for the interventions of autism, but its validity and feasibility remain to be proved.
Objective
This study aimed to investigate the effectiveness of digital health interventions (DHIs) in improving core symptoms or intelligence quotient in patients with autism spectrum disorder (ASD).
Methods
Three databases including PubMed, Cochrane, and Scopus, were searched on November 15, 2022. Randomized clinical trials that enrolled patients with ASD who received DHIs and a control group without DHI treatment were included. Cochrane risk of bias tool (RoB 2) was applied to assess the risk of bias.
Results
A total of 33 studies, involving 1285 participants (658 [51.2%] in DHI groups and 627 [48.8%] in control groups), were analyzed to investigate the differences between DHI groups and control groups. Significantly greater improvements in the overall performance of ASD were observed in the DHI groups compared to the control groups (including active, waitlist, treatment‐as‐usual, and no treatment) with an effect size of 1.89 (Cohen's d 95% confidence interval [CI]: 1.26–2.52). Studies with treatment‐as‐usual, waitlist, and no treatment control demonstrated large effect sizes of Cohen's d 3.41 (95% CI: 0.84–5.97), Cohen's d 4.27 (95% CI: 1.95–6.59), and Cohen's d 4.52 (95% CI: 2.98–6.06) respectively. In contrast, studies with active control revealed insignificant effect sizes (Cohen's d 0.73, 95% CI: 0.12–1.33).
Interpretation
This meta‐analysis found significantly greater improvements in core symptoms or intelligence quotient in ASD patients receiving DHIs compared to those in control conditions. ASD patients may benefit from the DHIs and reduce the economic burden.
... There is a strong evidence base for peer support. It has been shown to improve outcomes for people facing anxiety and depression, (14,17,18) and other mental health challenges, including addiction (19,20), trauma (21,22), and grief (23,24). For example, a recent study evaluating the effectiveness of peer support on the mental health of migrant workers in Singapore found signi cant reductions in depression, anxiety, and stress scores over a 6-month period as compared to baseline, making it an important mental health intervention even in the local context (17). ...
Background
Access to formal mental healthcare is low in Asia. Peer-support can be a viable alternative, gateway, or complement to formal mental healthcare. The current study examined interest in various types of peer support, including individual vs. group and virtual vs. in-person, among Singaporean adults with symptoms of anxiety or depression and their preferences and perceptions surrounding peer support.
Methods
A cross-sectional online survey was administered to members of a web panel. Participants with symptoms of depression or anxiety based on the Patient Health Questionnaire-4 screener were surveyed. Logistic regression analysis was conducted to examine factors associated with greater interest in peer support.
Results
350 panel members met our inclusion criteria. 62% indicated interest in receiving peer support. The strongest preference was for one-on-one support delivered virtually. Younger age (OR = 1.05, p < .01), working in white-collar managerial as opposed to white-collar non-managerial positions (OR = 1.96, p < .05), utilizing formal healthcare in the last 3 months (OR = 2.45, p < .05), and previously providing peer support (OR = 7.33, p < .01) were associated with greater interest in receiving peer support. Most of those not interested in peer support cited concerns around confidentiality.
Conclusions
Despite low uptake of formal mental healthcare, the majority of adult Singaporeans surveyed with anxiety or depression symptoms indicated interest in receiving peer support. Greater efforts to promote peer support programs can be part of a comprehensive strategy to address rising rates of poor mental health in Singapore.
... The experimental intervention in the 2006 study was Alcoholics Anonymous or other Twelve Step Facilitation (TSF) programs, while the control interventions were those of no treatment, other psychological interventions (such as Motivational Enhancement Therapy, Cognitive Behavioral Therapy, and Relapse Prevention Therapy), as well as Twelve-Step program variants (such as spiritual, nonspiritual, professionally led, lay led, etc). Additionally, the 2006 outcome measures consisted of severity of dependence or abuse (using the Addiction Severity Index); retention in, or drop out from, treatment; reduction of drinking; abstinence; and qualitative outcomes regarding patients and relatives' satisfaction (Ferri, Amato, and Davoli 2006). ...
This dissertation utilized mixed methods research to examine how nonreligious individuals with substance use disorders navigate recovery within—or in spite of—Alcoholics Anonymous (AA). Both the 12-step program itself and Alcoholics Anonymous have long been criticized for being religious and/or spiritual in nature, and some studies have shown that this is particularly challenging for nonreligious individuals seeking recovery. The purpose of this research was to (a) identify differences in recovery resources (recovery capital) between the religious, the nonreligious, those in AA, and those who have adopted alternative forms of recovery; (b) identify barriers that the nonreligious face as they navigate recovery within AA; and (c) identify common factors that underly a successful recovery.
Drawing from a sample of over 500 participants throughout the United States, I found that there were no statistically significant differences in recovery capital between the religious, the nonreligious, those in AA, and those with alternative forms of recovery. Additionally, interviews with 51 (predominantly nonreligious) individuals in recovery identified 6 barriers that the nonreligious face as they navigate AA: (1) Anxieties over being nonreligious and the belief that AA was religious; (2) The religious undertone and “God talk” in meetings; (3) Prayers in meetings; (4) The Big Book; (5) Discrimination; and (6) Fundamentalism. However, despite this, the nonreligious are able to find success in AA by creating their own unique “recovery toolbox” that consists of some, if not all, of the following: not working the 12 steps, creating an alternative higher power, drawing from outside resources, and practicing gratitude, meditation, and mindfulness. Additionally, the nonreligious create a space for themselves within AA by (a) being active and vocal about defending their nonreligious beliefs at meetings and (b) attending secular AA meetings. Aside from their personal recovery toolbox and actively creating their own space within AA, the nonreligious find the community itself to be the greatest asset to their recovery.
The findings of this research contribute to both public health literature and sociology of religion. It contributes to public health literature by providing a qualitative assessment of the efficacy of AA, specifically for a traditionally stigmatized group. Additionally, it contributes to the limited literature on nonreligious experiences in AA. This research also contributes to sociology of religion, as it offers support for theories that argue secularization and desecularization can be found in everyday institutions—in this case, AA. It also contributes to ongoing debates as to whether religious folks have better health outcomes compared to the nonreligious.
... The process includes different steps and goals that each member adheres to and accomplishes. Some common steps in the 12-step programs include: admitting that one cannot control one's addictive disorder, examining past mistakes with the help of an experienced member (i.e., sponsor), learning a new code of behavior and helping others who suffer from the same addiction ( Ferri et al., 2006 ). The American Psychiatric Association recommends * Correspondence author at: Department of Neuroscience, Imaging and Clinical Sciences, "G. ...
Background
: Following Covid-19 pandemic, lockdown strategies have been adopted by many Governments worldwide to stop the spread of the virus. Twelve-step programs for people with Substance Use Disorders (SUDs) as Narcotics Anonymous (NA) experienced forced interruption as well, in some cases organizing online meetings to continue their activities. The purpose of this article is to reflect on concerns and advantages of online setting for 12-step groups.
Methods
: We report the experience of an Italian NA participant attending for the first time an online NA group during Covid-19 pandemic.
Results
: Strengths and limitations of the remote setting, showing up from the living voice of this participant, are expressed in the light of the present pandemic situation. Together with the general advantages derived from telehealth technologies, specific benefits of the virtual setting for 12-step programs are shown. Concerns are also discussed, as those related to privacy and social presence.
Conclusions
: The case highlights many possibilities of online setting for 12-step programs. On the other hand, it suggests the critical importance of in-person groups to accompany the recovery process. Future outcome research is needed about the combination of these approaches.
... The different subtypes within the chronic AUD group may influence patients' attitudes to seek help and the planning of personalized therapeutic approaches as well [17]. Successful relapse prevention and complete abstinence could seem an unattainable treatment aim in severe, chronic AUD [41,42]. For example, evidence suggests that AUD groups characterized by increased externalizing symptoms seek less therapeutic help [17]. ...
Aims
Higher levels of externalizing characteristics, i.e. impulsivity, novelty seeking and aggression, could contribute to the development, progression and severity of alcohol use disorder (AUD). The present study aims to explore whether these externalizing characteristics together have a potential group-forming role in AUD using latent profile analysis (LPA).
Methods
Externalizing characteristics of 102 AUD patients were analyzed using LPA to explore the group-forming role of externalizing symptoms; groups were compared in terms of demographic and alcohol-related variables, indices of psychopathological, depressive and anxiety symptom severity.
Results
LPA revealed and supported a two-group model based on externalizing symptoms. The group with higher levels of externalizing symptoms showed significantly elevated levels of alcohol-related and anxio-depressive symptoms.
Conclusions
Externalizing characteristics converge and have a group-forming role in chronic AUD, and are associated with a more severe form of AUD. By making the diagnostic category less heterogeneous, these different subtypes within AUD may provide aid in tailoring treatments to patients’ specific needs.
... For example, in Nigeria, young people go into harmful drinking especially when they reach legal alcohol consumption age of 18 and starting to drink at an early age increases a person's chances of developing problems with alcohol use in later life [8] . More so, early alcohol use can be associated with behaviours such as unsafe sex, smoking, use of illegal drugs, and risktaking behaviours [9] . When negative effects of alcohol use disorder are not treated in time, they degenerate into biological, psychological, and social health problems. ...
Alcohol use disorder (AUD) has been identified as a major contributor to global burden of disease and
is among the mental disorders with lowest treatment rates. This study was carried out to assess the
prevalence of AUD and its treatment among undergraduates of Ekiti State University, Ado Ekiti,
Nigeria. This study was in two phases. In phase one, an epidemiological survey was employed where
multistage sampling technique was used to select participating students (N = 1751; Mean age = 21.53;
Males, N = 844; Mean age = 22.04, and Females N= 907; Mean age =21.05). Sociodemographic and
baseline data were collected in phase one through biodata form and Alcohol Use Disorder
Identification Test (AUDIT) respectively. Phase two employed randomized control trial design where
24 students who scored 7 (derived norm for AUDIT in this study) and above in AUDIT were
randomly assigned into three treatment groups (Cognitive Behaviour Therapy (CBT), Alcoholic
Anonymous (AA), CBT/AA-combined) and one control group. The prevalence of AUD among the
sampled population is as follows: (Total sampled population = 36%; males = 41.5%; females =
30.9%). The difference of pre and post-therapy tests were statistically significant for AUD (CBT
group: t (5) = 6.13, p <.01; AA group: t (5) = 4.59, p <.01; CBT/AA-combined group: t (5) = 3.71, p
<.05). The difference between pre and post therapy tests were statistically significant for dependence
use in CBT group: t (5) = 2.65, p< .05; but were not statistically significant for dependence use in AA
group: t (5) = 1.55, p = .18. and AA/CBT-combined group (t (5) = 2.37, p = .064). From these
findings, psychosocial approaches are needed to effectively assess and treat AUD. More so, treatment
facilities should be utilized and made available early to prevent students from going into dependence
phase of AUD. So, in order to reduce the prevalence of AUD among University Undergraduates, early
psychosocial detection and evidence based treatments of AUD should be prioritized in the schools to
avert physical, mental, and social harms of AUD
... All new members are encouraged to form a bond with a sponsorsomeone who has taken the 12 steps themselves and is willing to share their recovery journey. While AA and other 12-step programs have not been shown to be effective in achieving abstinence when compared to other psychosocial treatment programs, there is some evidence to suggest that the approach helps people to accept and remain in treatment (Ferri et al. 2006). Reflecting on the "helper therapy principle" (Reissman 1965), underpinning AA and other self-help groups (Zemore et al. 2004) found that engaging in helping otherse.g., sharing experiences, providing advice on getting helpwas more strongly predicative of improved outcomes than a passive involvement in the program. ...
... Facilities that did not offer MOUD relied on abstinence-based strategies, counseling, 12-step programs, physical recreation, and yoga, which have not been proven to significantly benefit those with OUD [25][26][27]. When questioned about MOUD, these Journal of Addiction and Recovery treatment facilities reported that they did not believe in the therapy with several even stating that "replacing one drug with another drug" was not the solution, a well-documented trope used against MOUD [21,28,29]. ...
Objective: Addressing the opioid epidemic requires an expansion of accessible, evidence-based treatment, particularly Medications for Opioid Use Disorder (MOUD). The common practice of residential "Detoxification" using methadone or buprenorphine to manage Opioid Use Disorder (OUD) without offering sustained treatment counters the evidence basis for MOUD. We evaluated the accessibility and prevalence of MOUD among residential treatment facilities in the US. Methods: This is a prospective "Secret Shopper" pilot study where facilities were contacted by telephone during business hours. We called 99 facilities randomly selected from the SAMHSA Facility Navigator website using a script-ed case-based questionnaire about accessing treatment and types of treatment offered. The survey mimicked a conversation between intake personnel and a family member of a patient with OUD. Results: Of 99 facilities contacted, investigators reached 66 (66.7%, 95% CI: [0.56,0.76]). MOUD was offered at 42 (63.6%, 95% CI: [0.52,0.74]) facilities for detoxification and only 5 (11.9%, 95% CI: [0.05,0.25]) for maintenance therapy. Buprenorphine was offered in 35 (53.0%, 95% CI: [0.41,0.65]). Systematic hurdles included the use of non-human automated menu by 20 facilities (30.3%, 95% CI: [0.20,0.43]), inability to address questions in 11 (16.7%, 95% CI: [0.09,0.28]), and the ability to obtain outcomes data from 13 (19.7%, 95% CI: [0.11,0.32]). Conclusion: Many facilities have not adopted evidence-based treatment strategies for OUD. It is difficult to contact facilities and obtain information regarding treatment. SAMHSA should enhance its website and provide guidance regarding evidence-based treatment. This can include a preference for centers that provide sustained MOUD and
... The Neutral Substance Use Evaluation may also recommend or mandate attendance at, or at least exposure to, some form of mutual help or support group. 4 This differs from 12 Step Facilitation (see Footnote 5), administered by a trained addiction provider, utilizing the principles of the 12 step mutual-help programs. Although Mutual Help Groups are not administered by a trained professional, not considered an evidence-based treatment, per se, and are not considered treatment at all by some, there is a strong body of evidence supporting the value and efficacy of participation in such groups (Connors et al., 2001;Ferri, Amato, & Davoli, 2006;Kaskutas, 2009;Kelly, Humphreys, & Ferri, 2020;Magura, Cleland, & Tonigan, 2013;Pagano, Friend, Tonigan, & Stout, 2004;PMRG, 1998). In an attempt to balance the readily available literature of other evidence-based treatments, current evidence supporting mutual help is elaborated in APPENDIX III. ...
In child custody litigation, protecting child safety during access with a parent with substance use disorder (SUD) presents a vexing challenge for the court, parents, and parents’ counsel. Standardization of monitoring protocols for this population is lacking. Monitoring protocols utilized in clinical settings and child welfare agencies are not necessarily applicable to child custody litigation. This article is the first of its kind to initiate standardization of monitoring protocols for parental substance use in child custody litigation. This article also proposes the inclusion of, and rationale for, a neutral evaluator and a separate neutral monitor to oversee the monitoring protocol. Topics that inform the practical aspects of protocol design and implementation, such as relapse risk, monitoring duration, treatment recommendations, mandated treatment, mutual help groups, and confidentiality, are described. Family courts and matrimonial counsel benefit from an understanding of the rationale for the evaluation, treatment, and monitoring of parental substance use disorders by individuals with expertise and/or certification in substance use disorders and forensic toxicology.
... "Mutual support" refers to the reciprocal provision of social, emotional and informational support by group members undergoing recovery from addiction (22). Although accumulating evidence points to the importance and benefit of participating in mutual support (23)(24)(25) a major limitation in developing a strong evidence base has been the lack of systematic outcome data evaluating routine service provision. Although 12-step models are traditionally the most well-known and accessed model of mutual support (26), other approaches (e.g., SMART Recovery) are gaining momentum. ...
Background: Routine outcome monitoring (ROM) has been implemented across a range of addiction treatment services, settings and organisations. Mutual support groups are a notable exception. Innovative solutions are needed. SMART Track is a purpose built smartphone app designed to capture ROM data and provide tailored feedback to adults attending Australian SMART Recovery groups for addictive behaviour(s).
Objective: Details regarding the formative stage of app development is essential, but often neglected. Improved consideration of the end-user is vital for curtailing app attrition and enhancing engagement. This paper provides a pragmatic example of how principles embedded in published frameworks can be operationalised to address these priorities during the design and development of the SMART Track app.
Methods: Three published frameworks for creating digital health technologies (“Person-Based Approach,” “BIT” Model and IDEAS framework) were integrated and applied across two stages of research to inform the development, design and content of SMART Track. These frameworks were chosen to ensure that SMART Track was informed by the needs and preferences of the end-user (“Person-Based”); best practise recommendations for mHealth development (“BIT” Model) and a collaborative, iterative development process between the multi-disciplinary research team, app developers and end-users (IDEAS framework).
Results: Stage one of the research process generated in-depth knowledge to inform app development, including a comprehensive set of aims (clinical, research/organisation, and usage); clear articulation of the target behaviour (self-monitoring of recovery related behaviours and experiences); relevant theory (self-determination and social control); appropriate behavioural strategies (e.g., behaviour change taxonomy and process motivators) and key factors that may influence engagement (e.g., transparency, relevance and trust). These findings were synthesised into guiding principles that were applied during stage two in an iterative approach to app design, content and development.
Conclusions: This paper contributes new knowledge on important person-centred and theoretical considerations that underpin a novel ROM and feedback app for people with addictive behaviour(s). Although person-centred design and best-practise recommendations were employed, further research is needed to determine whether this leads to improved usage outcomes.
Clinical Trial Registration: Pilot Trial: http://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377336.
... Rather than being driven by a zero tolerance policy to continued alcohol consumption, a harm reduction approach aims to curtail the personal and societal effects of alcohol dependence (Muckle et al., 2012). While AA was proven to be efficient at raising abstinence levels over time, over and above alternative interventions (Kelly et al., 2020), retention, severity of dependence and drinking consequence did not appear to be differentially influenced by comparative approaches (Ferri et al., 2006). In addition, the criticism of twelve step programs such as AA can likewise be attributed to the discouraging underlying message behind such a treatment program. ...
Background: The field of positive psychology is fast growing and ultimately aims to increase flourishing. As yet, these concepts have had very limited impact in the field of alcohol dependence. The aim of this study is to compare flourishing levels in people recovering from alcohol problems with two comparison groups.
Methods: An online survey was conducted with people recovering from alcohol problems (n = 107), a community sample of gym attenders (n = 185) and people with mental health problems (n = 130). They completed the PERMA Scale, as well as answering questions about their drinking.
Results: People recovering from alcohol problems scored better than the mentally ill sample on every aspect of the PERMA Scale. In contrast, they scored significantly worse on every subscale compared to the community gym attenders’ group. Responses to open-ended questions highlighted the costs of alcohol problems, especially in terms of losses experienced through drinking, along with an unhealthy tendency to focus on the past.
Conclusions: The abstinence model may reinforce a sense of hopelessness and powerlessness in those battling alcohol problems and may inhibit flourishing. There is a need to develop positive psychology interventions that may help individuals recovering from alcohol problems to flourish.
... Thus, there was no evidence from the review that the higher frequency of continuous abstinence in the AA/TSF group resulted in less frequency or intensity of drinking or less harm from drinking in that group compared with those treated by different methods. If continuous abstinence is claimed to be the crucial measure in the evaluation of AUD treatment success, it should surely be expected that it would be associated with less frequency and intensity of drinking and a reduction in the harm due to drinking among those who receive AA/TSF. Kelly et al. (2020b) state that their review updates and replaces an earlier Cochrane review by Ferri et al. (2006), which concluded that 'No experimental studies unequivocally demonstrated the effectiveness of AA or TSF approaches for reducing alcohol dependence or problems' (p.1). However, it is doubtful whether the findings of the later review can be said to replace those of the earlier because their conclusions rested on different outcome measures. ...
The present study attempted to assess the nature of violence against women and children during COVID-19 and identify the antecedent variables impacting such brutal human behavior.
Method: An interpretive worldview was adopted for the study using a qualitative exploratory method. The data for the study was extracted from newspaper reports about violence against women and children during the COVID-19 pandemic. Twenty (20) relevant cases were selected for the study. The study used QDA Miner for the content analysis of the cases. The proposed theoretical model posits that a set of proximal and distal variables are
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responsible for a surge in violence against women and children under the influence of external stressors, such as COVID-19-inflicted disruptions.
Results: Stress and anxiety, depression, decreasing self-respect, frustration, and hopelessness were identified as proximal variables, while the distal variables consolidated on increased workload, addiction, economic burden, attachment styles, relationship activities, and psychopathic. The impact of the proximal and distal variables on the consequences (violence against women and children) was found to increase under the influence of external stressors (COVID-19).
Conclusion: Women and children are vulnerable to disruptive changes. The pandemic, inflicted by COVID-19, has reinforced the notion. There is a risk that the departure of women from the workforce could become permanent, reversing gender equality gains and GDP gains. So, social work intervention's role in this problem is significant at the grassroots.
This review examines the body of literature on the effectiveness of Alcoholics Anonymous (AA), the relationship between spirituality and recovery, and the implications for nonreligious individuals in such settings. It spotlights research that documents the positive effects of spiritual transformations on recovery outcomes. Concurrently, it highlights the obstacles encountered by nonreligious participants in AA, including feelings of alienation due to the program’s emphasis on spirituality. The review concludes by stressing the necessity for additional studies into the experiences of nonreligious individuals within 12-step frameworks like AA, aiming to improve recovery practices for a growing nonreligious population.
Background:
Stimulant use disorder is a continuously growing medical and social burden without approved medications available for its treatment. Psychosocial interventions could be a valid approach to help people reduce or cease stimulant consumption. This is an update of a Cochrane review first published in 2016.
Objectives:
To assess the efficacy and safety of psychosocial interventions for stimulant use disorder in adults.
Search methods:
We searched the Cochrane Drugs and Alcohol Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, three other databases, and two trials registers in September 2023. All searches included non-English language literature. We handsearched the references of topic-related systematic reviews and the included studies.
Selection criteria:
We included randomised controlled trials (RCTs) comparing any psychosocial intervention with no intervention, treatment as usual (TAU), or a different intervention in adults with stimulant use disorder.
Data collection and analysis:
We used the standard methodological procedures expected by Cochrane.
Main results:
We included a total of 64 RCTs (8241 participants). Seventy-three percent of studies included participants with cocaine or crack cocaine use disorder; 3.1% included participants with amphetamine use disorder; 10.9% included participants with methamphetamine use disorder; and 12.5% included participants with any stimulant use disorder. In 18 studies, all participants were in methadone maintenance treatment. In our primary comparison of any psychosocial treatment to no intervention, we included studies which compared a psychosocial intervention plus TAU to TAU alone. In this comparison, 12 studies evaluated cognitive behavioural therapy (CBT), 27 contingency management, three motivational interviewing, one study looked at psychodynamic therapy, and one study evaluated CBT plus contingency management. We also compared any psychosocial intervention to TAU. In this comparison, seven studies evaluated CBT, two contingency management, two motivational interviewing, and one evaluated a combination of CBT plus motivational interviewing. Seven studies compared contingency management reinforcement related to abstinence versus contingency management not related to abstinence. Finally, seven studies compared two different psychosocial approaches. We judged 65.6% of the studies to be at low risk of bias for random sequence generation and 19% at low risk for allocation concealment. Blinding of personnel and participants was not possible for the type of intervention, so we judged all the studies to be at high risk of performance bias for subjective outcomes but at low risk for objective outcomes. We judged 22% of the studies to be at low risk of detection bias for subjective outcomes. We judged most of the studies (69%) to be at low risk of attrition bias. When compared to no intervention, we found that psychosocial treatments: reduce the dropout rate (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.74 to 0.91; 30 studies, 4078 participants; high-certainty evidence); make little to no difference to point abstinence at the end of treatment (RR 1.15, 95% CI 0.94 to 1.41; 12 studies, 1293 participants; high-certainty evidence); make little to no difference to point abstinence at the longest follow-up (RR 1.22, 95% CI 0.91 to 1.62; 9 studies, 1187 participants; high-certainty evidence); probably increase continuous abstinence at the end of treatment (RR 1.89, 95% CI 1.20 to 2.97; 12 studies, 1770 participants; moderate-certainty evidence); may make little to no difference in continuous abstinence at the longest follow-up (RR 1.14, 95% CI 0.89 to 1.46; 4 studies, 295 participants; low-certainty evidence); reduce the frequency of drug intake at the end of treatment (standardised mean difference (SMD) -0.35, 95% CI -0.50 to -0.19; 10 studies, 1215 participants; high-certainty evidence); and increase the longest period of abstinence (SMD 0.54, 95% CI 0.41 to 0.68; 17 studies, 2118 participants; high-certainty evidence). When compared to TAU, we found that psychosocial treatments reduce the dropout rate (RR 0.79, 95% CI 0.65 to 0.97; 9 studies, 735 participants; high-certainty evidence) and may make little to no difference in point abstinence at the end of treatment (RR 1.67, 95% CI 0.64 to 4.31; 1 study, 128 participants; low-certainty evidence). We are uncertain whether they make any difference in point abstinence at the longest follow-up (RR 1.31, 95% CI 0.86 to 1.99; 2 studies, 124 participants; very low-certainty evidence). Compared to TAU, psychosocial treatments may make little to no difference in continuous abstinence at the end of treatment (RR 1.18, 95% CI 0.92 to 1.53; 1 study, 128 participants; low-certainty evidence); probably make little to no difference in the frequency of drug intake at the end of treatment (SMD -1.17, 95% CI -2.81 to 0.47, 4 studies, 479 participants, moderate-certainty evidence); and may make little to no difference in the longest period of abstinence (SMD -0.16, 95% CI -0.54 to 0.21; 1 study, 110 participants; low-certainty evidence). None of the studies for this comparison assessed continuous abstinence at the longest follow-up. Only five studies reported harms related to psychosocial interventions; four of them stated that no adverse events occurred.
Authors' conclusions:
This review's findings indicate that psychosocial treatments can help people with stimulant use disorder by reducing dropout rates. This conclusion is based on high-certainty evidence from comparisons of psychosocial interventions with both no treatment and TAU. This is an important finding because many people with stimulant use disorders leave treatment prematurely. Stimulant use disorders are chronic, lifelong, relapsing mental disorders, which require substantial therapeutic efforts to achieve abstinence. For those who are not yet able to achieve complete abstinence, retention in treatment may help to reduce the risks associated with stimulant use. In addition, psychosocial interventions reduce stimulant use compared to no treatment, but they may make little to no difference to stimulant use when compared to TAU. The most studied and promising psychosocial approach is contingency management. Relatively few studies explored the other approaches, so we cannot rule out the possibility that the results were imprecise due to small sample sizes.
Alcohol-associated liver disease is the leading indication for hospitalization among patients with chronic liver disease. Rates of hospitalization for alcohol-associated hepatitis have been rising over the last 2 decades. Patients with alcohol-associated hepatitis carry significant morbidity and mortality, but there is a lack of standardized postdischarge management strategies to care for this challenging group of patients. Patients warrant management of not only their liver disease but also their alcohol use disorder. In this review, we will discuss outpatient management strategies for patients who were recently hospitalized and discharged for alcohol-associated hepatitis. We will discuss short management of their liver disease, long-term follow-up, and review-available treatment options for alcohol use disorder and challenges associated with pursuing treatment for alcohol use disorder.
The purpose of this dissertation has been to contribute knowledge about psychosocial factors that enables mastery for patients during the transition from inpatient SUD treatment to everyday life after discharge.
Published version can be found here (Norwegian): https://skriftserien.oslomet.no/index.php/skriftserien/article/view/759
Alcohol (EtOH) addiction can be characterized as a chronic relapsing disorder. EtOH craving is a critical precipitating factor to relapse. Environmental and conditioning cues can elicit drug-seeking ‘craving’ in both humans and rodents. The operant Pavlovian Spontaneous Recovery (PSR) model of EtOH-seeking is a unique and suitable model for studying ‘craving-like’ behavior as well as examining underlying neural systems and mechanisms that may be involved in ‘craving-like’ and, by extension, relapse behavior in rodents. Our objective is to provide the reader with details and methods on the benefits of using the PSR model to examine and better understand EtOH ‘craving-like’ behavior.Key words
Pavlovian Spontaneous recovery
Alcohol-seeking
Craving
Alcohol
Cues associated with alcohol use can readily enhance self-reported cravings for alcohol, which increases the likelihood of reusing alcohol. Understanding the neuronal mechanisms involved in alcohol-seeking behavior is important for developing strategies to treat alcohol use disorder. In all experiments, adult female alcohol-preferring (P) rats were exposed to three conditioned odor cues; CS+ associated with EtOH self-administration, CS- associated with the absence of EtOH (extinction training), and a CS0, a neutral stimulus. The data indicated that presentation of an excitatory conditioned cue (CS+) can enhance EtOH- seeking while the CS- can inhibit EtOH-seeking under multiple test conditions. Presentation of the CS+ activates a subpopulation of dopamine neurons within the interfascicular nucleus of the posterior ventral tegmental area (posterior VTA) and basolateral amygdala (BLA). Pharmacological inactivation of the BLA with GABA agonists inhibits the ability of the CS+ to enhance EtOH-seeking but does not alter context-induced EtOH-seeking or the ability of the CS- to inhibit EtOH-seeking. Presentation of the conditioned odor cues in a non-drug-paired environment indicated that presentation of the CS+ increased dopamine levels in the BLA. In contrast, presentation of the CS- decreased both glutamate and dopamine levels in the BLA. Further analysis revealed that presentation of a CS+ EtOH-associated conditioned cue activates GABA interneurons but not glutamate projection neurons. Overall, the data indicate that excitatory and inhibitory conditioned cues can contrarily alter EtOH-seeking behaviors and that different neurocircuitries are mediating these distinct cues in critical brain regions. Pharmacotherapeutics for craving should inhibit the CS+ and enhance the CS- neurocircuits.
The aim of this Research Topic, Human Connection as a Treatment for Addiction, is to bring together scholars from various fields to explore the question of whether intentionally increasing meaningful, caring interaction between people may reduce substance and/or non-substance related addictive behaviors. Previous research supports the role that social connection may play in the initiation and maintenance of addiction in both animals and humans (van der Eijk and Uusitalo,
2016; Christie, 2021).
Background:
According to the new criteria in the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-V), the prevalence of alcohol use disorders (AUDs) is 20-30% in men and 10-15% in women worldwide 2,3. The anticraving therapy/ psychotherapy combination is currently used routinely in clinical practice. However, the results after one year are unsatisfactory. Meta-analytic studies found failure rates of 57 to 75%. These percentages vary in relation to the intensity and length of the treatment. In addition, the abstinence rates gradually decrease over time. In this study, the clinical outcome of alcohol related liver disease (ALD) patients who spontaneously attended self-help groups (SHGs) (club of alcoholics in treatment - multi-family community/ alcoholics anonymous) regularly versus those who did not want to start the path or did not complete it was evaluated.
Methods:
1337 alcohol use disorder patients affected by compensated alcohol related liver disease followed prospectively from January 2005 to December 2010, were retrospectively assessed. 231 patients were enrolled: 74 attended self-help groups assiduously, 27 attended sporadically and 130 refused participation in SHGs.
Results:
Constant attendance at SHGs compared to non-attendance allows for a significant increase (<0.0001) in the period of sobriety found in the median of distribution. Frequent attendance at SHGs is effectively "preventive", reducing the fraction of relapses by about 30%. The percentage of cases of cirrhosis is significantly different (p = 0.0007) between those who have regularly attended SHG meetings (about 1% of patients) and those who have never attended or only occasionally (various percentages between 21 and 31% of patients); in both groups the incidence of new cases would seem to be 0.014 cases/ year. Similar difference in percentages regarding the onset of hepatocellular carcinomas (HCCs), although with a lower level of significance (p = 0.017) among those who attended regularly, 4% of patients with an incidence of 0.006 cases/ year, compared to those who have never attended or only occasionally: over 14% of patients with an incidence of 0.022 cases/ year.
Conclusions:
This study suggests the importance of attending SHGs not only for the long-term achievement of alcoholic abstention, but also in positively influencing the course of alcohol-related diseases.
Objective: This report aims to identify US mutual help group (MHG) participants' psycho-socio-behavioral profiles. Method: We used data from the 2015-2018 National Survey on Drug Use and Health and the sample included 1022 adults with past-year substance use disorders (SUD). We conducted a latent class analysis to identify subgroups of MHG participants and estimated multinomial logistic regression models to examine the associations between sociodemographic/intrapersonal characteristics and class membership. Results: Analyses identified three latent classes. Class 1 (Low-Risk group, 54%) reported low risks in all correlates except for serious psychological distress (SPD, 33%). Class 2 (Psychological Distress group, 30%) demonstrated high risks of major depressive episodes (86%) and SPD (93%). Class 3 (Criminal Justice System Involvement group, 16%) showed high involvement in arrests (100%) and drug-related arrests (67%) and moderate risks for SPD (54%) and behavioral problems, e.g., drug selling (46%) and theft (35%). Compared to Class 1, Class 2 was more likely to be female, out of the labor force, and to show high risk propensity, and Class 3 was more likely to have lower education and drug use disorders. Class 3 was also less likely to be older, belong to the "other" racial/ethnic category, have lower English proficiency, and report alcohol use disorder. Conclusions: The three subgroups of the US MHG participant population illustrate the complex and heterogeneous psycho-social-behavioral profiles of MHG participants with SUD. MHG referral's effectiveness may be augmented by tailoring it to the patient/client's specific psycho-socio-behavioral profile.
Background:
The aim of this meta-analysis was to assess the impact of operative blood loss on short and long-term outcomes following colorectal cancer surgery.
Methods:
A systematic literature review and meta-analysis were performed, from inception to the 10th of August 2020. A comprehensive literature search was performed on the 10th of August 2020 of PubMed MEDLINE, Embase, Science Citation Index Expanded, and Cochrane Central Register of Controlled Trials. Only studies reporting on operative blood loss and postoperative short term or long-term outcomes in colorectal cancer surgery were considered for inclusion.
Results:
Forty-three studies were included, reporting on 59,813 patients. Increased operative blood loss was associated with higher morbidity, for blood loss greater than 150-350 ml (odds ratio [OR] 2.09, p < 0.001) and > 500 ml (OR 2.29, p = 0.007). Anastomotic leak occurred more frequently for blood loss above a range of 50-100 ml (OR 1.14, p = 0.007), 250-300 ml (OR 2.06, p < 0.001), and 400-500 ml (OR 3.15, p < 0.001). Postoperative ileus rate was higher for blood loss > 100-200 ml (OR 1.90, p = 0.02). Surgical site infections were more frequent above 200-500 ml (OR 1.96, p = 0.04). Hospital stay was increased for blood loss > 150-200 ml (OR 1.63, p = 0.04). Operative blood loss was significantly higher in patients that suffered morbidity (mean difference [MD] 133.16 ml, p < 0.001) or anastomotic leak (MD 69.56 ml, p = 0.02). In the long term, increased operative blood loss was associated with worse overall survival above a range of 200-500 ml (hazard ratio [HR] 1.15, p < 0.001), and worse recurrence-free survival above 200-400 ml (HR 1.33, p = 0.01). Increased blood loss was associated with small bowel obstruction caused by colorectal cancer recurrence for blood loss higher than 400 ml (HR 1.97, p = 0.03) and 800 ml (HR 3.78, p = 0.02).
Conclusions:
Increased operative blood loss may adversely impact short term and long-term postoperative outcomes. Measures should be taken to minimize operative blood loss during colorectal cancer surgery. Due to the uncertainty of evidence identified, further research, with standardised methodology, is required on this important subject.
Infections in patients with neutropenia following chemotherapy are mostly manifested as fever (febrile neutropenia, FN). Some of the most important determinants of the risk of FN are the type of chemotherapy, the dose intensity and patient-specific factors. When the risk of FN is 20% or more granulopoiesis is prophylactically stimulated with granulocyte colony stimulating factor (G-CSF) after the treatment. Anemia should always be clarified and if necessary be treated according to the cause when symptomatic. If an absolute or functional iron deficiency is present, intravenous iron substitution is mostly necessary. Erythropoiesis-stimulating agents can be used after chemotherapy with hemoglobin (Hb) levels less than 10 g/dl (6.2 mmol/l). In cases of chronic anemia and Hb levels less than 7–8 g/dl (<4.3–5.0 mmol/l) the indications for transfusion of erythrocyte concentrates should be assessed primarily based on the individual clinical symptoms.
Background
Alcohol use disorders (AUDs) affect 15 million people nationwide, 4% of which are adolescents (ages 12-17) and adolescents who binge drink significantly increase their likelihood of suffering from an AUD in adulthood. Research shows that cues (i.e. flavors) paired with alcohol (EtOH) produce significant cue-induced alcohol craving and contribute to relapse in adolescent and adult populations. However, there is a lack of research focused on how cues that accompany EtOH drinking during adolescence, affect EtOH craving later in life. The current study sought to examine the sex- and developmental-dependent effects of adolescent exposure to flavor cues associated with EtOH on operant-lick behavior and cue-induced dopamine (DA) levels within the nucleus accumbens shell (AcbSh; reward structure) in adulthood.
Methods
Adolescent alcohol-preferring (P) rats were randomly assigned to one of 4 groups and received 24 hr. access to three bottles on their home cage: Paired: 0.1% blueberry flavor extract (BB) + 15% v/v EtOH and 2 water bottles; Unpaired: 0.1% BB, 15% v/v EtOH, and water; 15% EtOH alone, and 2 water bottles; BB alone and 2 water bottles. Home cage fluid consumption was measured for 2-weeks. On the third week bottles were removed and all animals underwent 9 days of operant training using an operant sipper paradigm. This consisted of two sipper spouts connected to the computer by a lickometer, which registered tongue contacts with the sipper tube (Paired: BB+EtOH or water; Unpaired BB or EtOH; EtOH alone: EtOH or water; BB alone: BB or water). When the fixed ratio (FR) requirement for number of licks/tongue contacts was met, a liquid delivery solenoid dispensed 0.05 ml of fluid into the sipper tube. Following the final operant session all rats remained in their home-cage for approximately 40 days until adulthood at which point they were returned to the operant chambers and tested for appetitive and consummatory behavior in response to the flavor cue (all rats: BB or water; NO EtOH). Two weeks after the final operant session all rats underwent microdialysis testing to examine cue-induced DA levels in the AcbSh. Results: Data indicated that animals in the paired group exhibited a significantly greater level of licking at the BB sipper and a significantly greater level of DA release in response to the flavor cue compared to the other groups.
Conclusions
Overall, the data suggest that cues paired with EtOH during adolescence may produce persistent changes to the behavioral and neurobiological mechanisms that contribute to an increased risk of developing an AUD later in life.
Co-occurring disorders are prevalent across multiple cultural contexts affecting individuals of varying socioeconomic, racial, and occupational backgrounds, often with devastating consequences. Individuals with substance use disorders and mental illness have an increased risk of suicide and adverse events, frequently made worse by higher rates of leaving hospitals against medical advice. Unfortunately, healthcare systems across the world have difficulty effectively treating patients with co-occurring disorders due to social and systemic barriers. Public policy interventions and multifactorial internal reform are needed to better engage this population.
Background
There is no consensus on how to best achieve a low central venous pressure during hepatectomy for the purpose of reducing blood loss and red blood cell (RBC) transfusions. We analyzed the associations between intraoperative hypovolemic phlebotomy (IOHP), transfusions, and postoperative outcomes in cancer patients undergoing hepatectomy.Methods
Using surgical and transfusion databases of patients who underwent hepatectomy for cancer at one institution (11 January 2011 to 22 June 2017), we retrospectively analyzed associations between IOHP and RBC transfusion on the day of surgery (primary outcome), and with total perioperative transfusions, intraoperative blood loss, and postoperative complications (secondary outcomes). We fitted logistic regression models by inverse probability of treatment weighting to adjust for confounders and reported adjusted odds ratio (aOR).ResultsThere were 522 instances of IOHP performed during 683 hepatectomies, with a mean (standard deviation) volume of 396 (119) mL. The IOHP patients had a 6.9% transfusion risk on the day of surgery compared with 12.4% in non-IOHP patients (aOR, 0.53; 95% confidence interval [CI], 0.29 to 0.98; P = 0.04). Total perioperative RBC transfusion tended to be lower in IOHP patients compared with non-IOHP patients (14.9% vs 22.4%, respectively; aOR, 0.72; 95% CI, 0.44 to 1.16; P = 0.18). In patients with a predicted risk of ≥ 47.5% perioperative RBC transfusion, 24.6% were transfused when IOHP was used compared with 56.5% without IOHP. The incidence of severe postoperative complications (Clavien–Dindo scores ≥ 3) was similar in patients whether or not IOHP was performed (15% vs 16% respectively; aOR, 0.97; 95% CI, 0.53 to 1.54; P = 0.71).Conclusions
The use of IOHP during hepatectomy was associated with less RBCs transfused on the same day of surgery. Trials comparing IOHP with other techniques to reduce blood loss and transfusion are needed in liver surgery.
These paragraphs begin an account of what would arguably prove the most impactful peer-mentoring intervention of the twentieth century: Alcoholics Anonymous (AA). Bill Wilson, the narrator of the story above, is recounting a meeting he had with his friend Ebby Thacher. Wilson had endured numerous unsuccessful hospitalizations for alcoholism and had nearly given up hope that his condition could ever be treated when Thacher visited with the news that he had managed to remain abstinent from alcohol for a sustained period of time:
Появление данной статьи вызвано многочисленными публикациями, дискредитирующими методы опосредованной психотерапии аддикций (ОП) и представляющие их как «сциентистски декорированное шаманство». В качестве основных причин подобной критики авторы статьи отмечают явно недостаточное, особенно в последнее время, количество научных исследований ОП и, соответственно, дефицит убедительных концепций. Рассматривая феномены патологического влечения (ПВ) и ОП с позиций информатики, авторы выделяют ПВ в структуре аддикций в качестве самостоятельного «программного продукта» и предлагают концепцию, согласно которой основным эффектом ОП является формирование антикревинговой программы на подсознательном уровне на основе вовлечения «функции самосохранения». Проводится параллель с антивирусными компьютерными программами. Уточняется важная роль ОП в алгоритме системной терапии аддиктивной патологии.
This article is a response to numerous publications, in which methods of mediated psychotherapy of addictions (MP), based on placebo and trance effects, are discredited and presented as »scientific-decorated shamanism». According to the authors, the main reasons for such criticism are insufficient amount of scientific studies of MP (especially in recent times) and as a result - the lack of convincing conceptions. Discussing phenomena of pathological craving (PC) and MP from the point of view of informatics, authors distinguish PC in the structure of addiction as an independent »software product». They offer the concept, according to which the main effect of MP is forming of unconscious anticraving program (similarly to antivirus computer programs) based on self-preservation function. Authors specify important role of MP in the algorithm of systematic treatment of addictions.
Появление данной статьи вызвано многочисленными публикациями, дискредитирующими методы опосредованной психотерапии аддикций (ОП) и представляющие их как «сциентистски декорированное шаманство». В качестве основных причин подобной критики авторы статьи отмечают явно недостаточное, особенно в последнее время, количество научных исследований ОП и, соответственно, дефицит убедительных концепций. Рассматривая феномены патологического влечения (ПВ) и ОП с позиций информатики, авторы выделяют ПВ в структуре аддикций в качестве самостоятельного «программного продукта» и предлагают концепцию, согласно которой основным эффектом ОП является формирование антикревинговой программы на подсознательном уровне на основе вовлечения «функции самосохранения». Проводится параллель с антивирусными компьютерными программами. Уточняется важная роль ОП в алгоритме системной терапии аддиктивной патологии.
This article is a response to numerous publications, in which methods of mediated psychotherapy of addictions (MP), based on placebo and trance effects, are discredited and presented as »scientific-decorated shamanism». According to the authors, the main reasons for such criticism are insufficient amount of scientific studies of MP (especially in recent times) and as a result - the lack of convincing conceptions. Discussing phenomena of pathological craving (PC) and MP from the point of view of informatics, authors distinguish PC in the structure of addiction as an independent »software product». They offer the concept, according to which the main effect of MP is forming of unconscious anticraving program (similarly to antivirus computer programs) based on self-preservation function. Authors specify important role of MP in the algorithm of systematic treatment of addictions.
Stroke is the second leading cause of death and a leading cause of disability worldwide. This invaluable reference provides clinicians caring for stroke patients with ready access to the optimal evidence for best practice in stroke prevention, acute stroke treatment, and stroke recovery. Now an edited volume, the editors and authors, many of whom are members of the Cochrane Stroke Review Group, describe all available medical, endovascular, and surgical treatments; the rationale for using them; and the strength of the evidence for their safety and effectiveness. New chapters cover key, rapidly advancing therapeutic topics, including prehospital stroke care and regionalized stroke systems, endovascular reperfusion therapy, and electrical and magnetic brain stimulation to enhance recovery. This is an essential resource for clinicians translating into practice the many dramatic advances that have been made in the treatment and prevention of stroke, and suggesting the most appropriate interventions.
Alcoholism, also known as Alcohol Use Disorder (AUD), is a serious problem affecting millions of people worldwide. Recovery from AUD is known to be challenging and often leads to relapse at various points after enrolling in a rehabilitation program such as Alcoholics Anonymous (AA). In this work, we present a structured and linguistic approach using hinge-loss Markov random fields (HL-MRFs) to understand recovery and relapse from AUD using social media data. We evaluate our models on AA-attending users extracted from: (i) the Twitter social network and predict recovery at two different points—90 days and 1 year after the user joins AA, respectively, and (ii) the Reddit AA recovery forums and predict whether the participating user is currently sober. The two datasets present two facets of the same underlying problem of understanding recovery and relapse in AUD users. We flesh out different characteristics in both these datasets: (i) In the Twitter dataset, we focus on the social aspect of the users and the relationship with recovery and relapse, and (ii) in the Reddit dataset, we focus on modeling the linguistic topics and dependency structure to understand users’ recovery journey. We design a unified modeling framework using HL-MRFs that takes the different characteristics of both these platforms into account. Our experiments reveal that our structured and linguistic approach is helpful in predicting recovery in users in both these datasets. We perform extensive quantitative analysis of different groups of features and dependencies among them in both datasets. The interpretable and intuitive nature of our models and analysis is helpful in making meaningful predictions and can potentially be helpful in identifying and preventing relapse early.
The comparative effectiveness of 12-step and cognitive–behavioral (C-B) models of substance abuse treatment was examined among 3, 018 patients from 15 programs at U.S. Department of Veterans Affairs Medical Centers. Across program types, participants showed significant improvements in functioning from treatment admission to a 1-year follow-up. Although 12-step patients were somewhat more likely to be abstinent at the 1-year follow-up, 12-step, C-B, and combined 12-Step–C-B treatment programs were equally effective in reducing substance use and improving most other areas of functioning. The finding of equal effectiveness was consistent over several treatment subgroups: Patients attending the “purest” 12-step and C-B treatment programs, and patients who had received the “full dose” of treatment. Also, patients with only substance abuse diagnoses, those with concomitant psychiatric diagnoses, and patients who were mandated to treatment showed similar improvement at the 1-year follow-up, regardless of type of treatment received. These data provide important new evidence supporting the effectiveness of 12-step treatment.
What follows is the second of two chapters devoted to a cognitive-behavioral approach to the treatment of alcohol abuse and dependence. The goal of this chapter is to present an overview of a cognitive-behavioral approach to the problem of relapse, relapse prevention therapy (RPT).
This study presents estimates of lifetime and 12-month prevalence of 14 DSM-III-R psychiatric disorders from the National Comorbidity Survey, the first survey to administer a structured psychiatric interview to a national probability sample in the United States.
The DSM-III-R psychiatric disorders among persons aged 15 to 54 years in the noninstitutionalized civilian population of the United States were assessed with data collected by lay interviewers using a revised version of the Composite International Diagnostic Interview.
Nearly 50% of respondents reported at least one lifetime disorder, and close to 30% reported at least one 12-month disorder. The most common disorders were major depressive episode, alcohol dependence, social phobia, and simple phobia. More than half of all lifetime disorders occurred in the 14% of the population who had a history of three or more comorbid disorders. These highly comorbid people also included the vast majority of people with severe disorders. Less than 40% of those with a lifetime disorder had ever received professional treatment, and less than 20% of those with a recent disorder had been in treatment during the past 12 months. Consistent with previous risk factor research, it was found that women had elevated rates of affective disorders and anxiety disorders, that men had elevated rates of substance use disorders and antisocial personality disorder, and that most disorders declined with age and with higher socioeconomic status.
The prevalence of psychiatric disorders is greater than previously thought to be the case. Furthermore, this morbidity is more highly concentrated than previously recognized in roughly one sixth of the population who have a history of three or more comorbid disorders. This suggests that the causes and consequences of high comorbidity should be the focus of research attention. The majority of people with psychiatric disorders fail to obtain professional treatment. Even among people with a lifetime history of three or more comorbid disorders, the proportion who ever obtain specialty sector mental health treatment is less than 50%. These results argue for the importance of more outreach and more research on barriers to professional help-seeking.
After initial interviews with 20,291 adults in the National Institute of Mental Health Epidemiologic Catchment Area Program, we estimated prospective 1-year prevalence and service use rates of mental and addictive disorders in the US population. An annual prevalence rate of 28.1% was found for these disorders, composed of a 1-month point prevalence of 15.7% (at wave 1) and a 1-year incidence of new or recurrent disorders identified in 12.3% of the population at wave 2. During the 1-year follow-up period, 6.6% of the total sample developed one or more new disorders after being assessed as having no previous lifetime diagnosis at wave 1. An additional 5.7% of the population, with a history of some previous disorder at wave 1, had an acute relapse or suffered from a new disorder in 1 year. Irrespective of diagnosis, 14.7% of the US population in 1 year reported use of services in one or more component sectors of the de facto US mental and addictive service system. With some overlap between sectors, specialists in mental and addictive disorders provided treatment to 5.9% of the US population, 6.4% sought such services from general medical physicians, 3.0% sought these services from other human service professionals, and 4.1% turned to the voluntary support sector for such care. Of those persons with any disorder, only 28.5% (8.0 per 100 population) sought mental health/addictive services. Persons with specific disorders varied in the proportion who used services, from a high of more than 60% for somatization, schizophrenia, and bipolar disorders to a low of less than 25% for addictive disorders and severe cognitive impairment. Applications of these descriptive data to US health care system reform options are considered in the context of other variables that will determine national health policy.
Genetic influences on alcoholism risk are well-documented in men, but uncertain in women. We tested for gender differences in genetic influences on, and risk-factors for, DSM-III-R alcohol dependence (AD).
Diagnostic follow-up interviews were conducted in 1992-3 by telephone with twins from an Australian twin panel first surveyed in 1980-82 (N = 5889 respondents). Data were analysed using logistic regression models.
Significantly higher twin pair concordances were observed in MZ compared to DZ same-sex twin pairs in women and men, even when data were weighted to adjust for over-representation of well-educated respondents, and for selective attrition. AD risk was increased in younger birth cohorts, in Catholic males or women reporting no religious affiliation, in those reporting a history of conduct disorder or major depression and in those with high Neuroticism, Social Non-conformity, Toughmindedness, Novelty-Seeking or (in women only) Extraversion scores; and decreased in 'Other Protestants', weekly church attenders, and university-educated males. Controlling for these variables, however, did not remove the significant association with having an alcoholic MZ co-twin, implying that much of the genetic influence on AD risk remained unexplained. No significant gender difference in the genetic variance in AD was found (64% heritability, 95% confidence interval 32-73%).
Genetic risk-factors play as important a role in determining AD risk in women as in men. With the exception of certain sociocultural variables such as religious affiliation, the same personality, sociodemographic and axis I correlates of alcoholism risk are observed in women and men.
Treatment for alcohol dependence is often provided in outpatient settings, and often includes introduction to Alcoholics Anonymous (AA). Relatively little is known about subsequent AA utilization. Analyses of survey data collected from 72 clients of an outpatient treatment center introduced to AA revealed that, 6 months following intake, a large portion of the responding sample of 55 were still attending AA meetings. Principal components analysis of self-reports of the frequencies of 12 AA-related behaviors found three dimensions of AA utilization: fellowship or social involvement, meeting attendance and participation, and involvement in bureaucratic functioning and meeting production. Results suggest it is important to consider these dimensions of utilization for those wishing to understand AA involvement.
Presumptive support was sought for mechanisms of action whereby two conceptually distinct aftercare programs, relapse prevention (RP) and 12-Step facilitation (TSF), impact upon substance abusers.
Adults who had just completed intensive treatment were assigned randomly to either RP (n=61) or TSF (n=70) aftercare programs.
Three residential treatment facilities.
Trained counselors delivered to small groups a manualized aftercare program which focused either upon the utilization of cognitive-behavioral processes to orchestrate change through an individualized treatment plan (i.e. RP) or which sought to facilitate utilization of AA's 12 Steps (i.e. TSF).
Process measures developed specifically to quantify either: (a) the changes in self-efficacy process in RP or (b) the utilization of AA's principles in TSF, as well as psychosocial and substance abuse indices were administered to all patients pre- and post-aftercare and at 6-month follow-up.
A significant relationship between changes in measures of self- efficacy for RP participants as well as a trend for a relationship between process-specific change for TSF participants partially satisfied the first condition for presumptive support. The fact that the intervention-specific mediators covaried with several outcome indices, and that removal of such mediators attenuated prediction of outcome met, respectively, the second and third conditions for presumptive support.
Carefully orchestrated RP and TSF aftercare programs yield process changes that are related positively to improved outcome.
This study investigated matching client attributes to different aftercare treatments. A naturalistic sample of adults entering substance abuse treatment was randomized into either Structured Relapse Prevention (RP, n=61) or a 12-Step Facilitation (TSF, n=72) aftercare program. Four patient attributes were matched to treatment: age, gender, substance abuse profile, and psychological status. Substance use outcomes were assessed 3 and 6 months posttreatment. At 6 months, four significant matches were uncovered. Females and individuals with a multiple substance abuse profile reported better alcohol outcomes with TSF aftercare than their cohorts exposed to RP aftercare. Individuals with high psychological distress at treatment entry were able to maintain longer periods of posttreatment abstinence with TSF aftercare compared to their cohorts exposed to RP. Inversely, RP was found to maintain abstinence significantly longer for individuals reporting low distress compared to those with high distress. Finally, better outcomes were achieved when random assignment to aftercare was consistent with participant preference. Overall, an Alcoholics Anonymous approach to aftercare appears to provide the most favorable substance use outcomes for most groups of substance abusers. RP may be most suitable for clients whose psychological distress is low, especially where maintenance of abstinence is targeted. Where choice in aftercare program is possible, matching client preference with type of aftercare program can improve outcome.
A positive corelation between Alcoholics Anonymous (AA) involvement and better alcohol-related outcomes has been identified in research studies, but whether this correlation reflects a causal relationship remains a subject of meaningful debate. The present study evaluated the question of whether AA affiliation appears causally related to positive alcohol-related outcomes in a sample of 2,319 male alcohol-dependent patients. An initial structural equation model indicated that 1-year posttreatment levels of AA affiliation predicted lower alcohol-related problems at 2-year follow-up, whereas level of alcohol-related problems at 1-year did not predict AA affiliation at 2-year follow-up. Additional models found that these effects were not attributable to motivation or psychopathology. The findings are consistent with the hypothesis that AA participation has a positive effect on alcohol-related outcomes.
Predicting outcomes for individual patients entering substance abuse treatment has long been a clinical goal in the addictions field. Intake data from the Addiction Severity Index and other standardized scales were collected on 248 alcohol dependent/abusing patients entering an urban hospital treatment program. The outcome measure was frequency of drinking days in the past 30 days. Baseline data were used to identify predictors of posttreatment drinking frequency at two follow-up interviews (3 and 12 months postbaseline). Stepwise multiple regressions indicated that a set of baseline predictors accounted for similar and substantial proportions of outcome variance at the two follow-ups. When psychosocial predictors were combined with an index of alcohol use severity (which included drinking frequency), the proportions of variance explained were 31% and 28% at 3 and 12 months, respectively. Two psychosocial predictors were significant at both time periods, and thus most likely to be replicated in future research: a treatment motivation index (a combination of measures of commitment to treatment success and internal motivation to seek treatment) and an index of 12-step (self-help) participation (a combination of measures of frequency of 12-step meeting attendance and perceived helpfulness of 12-step participation). While the predictability of short-term (3 month) outcomes could help clinicians tailor treatment strategies to maximize patient motivation and reduce drinking behavior, the predictability of longer term (12 month) outcomes could help counselors plan aftercare programs, encourage self-help participation, and promote recovery-oriented activities to sustain initial treatment-induced gains.
This study investigates the relationship between attendance at Alcoholics Anonymous (AA) meetings prior to, during, and after leaving treatment, and changes in clinical outcome following inpatient alcohol treatment.
A longitudinal design was used in which participants were interviewed at admission (within 5 days of entry), and 6 months following departure. The sample comprised 150 patients in an inpatient alcohol treatment programme who met ICD-10 criteria for alcohol dependence. The full sample was interviewed at admission to treatment. Six months after departure from treatment, 120 (80%) were re-interviewed.
Significant improvements in drinking behaviours (frequency, quantity and reported problems), psychological problems and quality of life were reported. Frequent AA attenders had superior drinking outcomes to non-AA attenders and infrequent attenders. Those who attended AA on a weekly or more frequent basis after treatment reported greater reductions in alcohol consumption and more abstinent days. This relationship was sustained after controlling for potential confounding variables. Frequent AA attendance related only to improved drinking outcomes. Despite the improved outcomes, many of the sample had alcohol and psychiatric problems at follow-up.
The importance of aftercare has long been acknowledged. Despite this, adequate aftercare services are often lacking. The findings support the role of Alcoholics Anonymous as a useful aftercare resource.
This study of dual diagnosis patients examined the associations of the intensity of acute care services and 12-step self-help group attendance with substance use and mental health outcomes.
Participants (n = 230; 96% men) received treatment in one of 14 residential programs and were evaluated with the Addiction Severity Index at discharge (98%) and at 1-year follow-up (80%).
High service intensity in acute treatment was associated with better substance use and family/social outcomes both at discharge and at 1 year when patients' intake status was controlled. More attendance at 12-step self-help groups was also associated with better patient substance use and psychiatric outcomes, both during and following treatment. The benefits of more 12-step group attendance, however, depended on whether acute treatment was of low or high service intensity. More 12-step group attendance during treatment was associated with better alcohol and drug outcomes at discharge only among patients treated in low-service-intensity programs; and more attendance postdischarge was associated with better psychiatric and family/social functioning at 1 year only among patients receiving low-service-intensity care.
We suggest potential means by which high-service-intensity acute care programs might better facilitate patients' postdischarge use of 12-step self-help groups to benefit outcomes.
The purpose of this study is to examine how helping activities and spirituality--perhaps key influences on sobriety--change over recovery. The study also explores interrelations among Alcoholics Anonymous (AA), helping and spirituality.
Questionnaires were administered to recovering alcoholics (118 men, 80 women) recruited at AA and Women for Sobriety meetings, treatment programs and through personal connections. A helping scale measured Recovery Helping (8-item alpha = 0.78), Life Helping (12-item alpha = 0.62), and Community Helping (6-item alpha = 0.60). The Daily Spiritual Experiences scale assessed two components of spirituality identified by factor analysis: Theism and Self-Transcendence. Two components of an AA scale, Involvement and Achievement, were also treated separately on the basis of factor analysis.
Structural equation modeling revealed that longer sobriety predicted significantly more time spent on Community Helping, less time spent on Recovery Helping and higher levels of Theism, Self-Transcendence and AA Achievement. Model covariances revealed that both AA components were related to more Recovery Helping and higher Theism. Both spirituality components related to all forms of helping, with one exception.
The findings highlight important changes in helping with length of sobriety. As their sobriety accumulates, recovering alcoholics seem to devote less time to informal helping and more time to organized community projects--perhaps indicating evolving needs and abilities. The results also suggest roles for AA and spirituality in encouraging helping, and they indicate that some forms of spirituality relate to AA affiliation. Future work might establish whether and when helping in different domains contributes to the maintenance of abstinence and to other drinking-related outcomes.
Forty-eight patients undergoing inpatient detoxification for alcohol dependence were assigned to either brief advice (BA) to attend Alcoholics Anonymous or a motivational enhancement for 12-step involvement (ME-12) intervention that focused on increasing involvement in 12-step self-help groups. Attendance at 12-step groups did not differ significantly by treatment condition over 6 months of follow-up, nor did drinking outcomes. There was a significant interaction between 12-step experience and treatment condition, indicating that ME-12 was associated with relatively better alcohol outcomes at the low ends of 12-step experience, whereas BA was associated with relatively better outcomes at the high ends of 12-step experience. Results indicate that among patients undergoing alcohol detoxification, ME-12 may be beneficial only for those who have little experience with 12-step groups.
Ninety men with alcohol problems and their female partners were randomly assigned to 1 of 3 outpatient conjoint treatments: alcohol behavioral couples therapy (ABCT), ABCT with relapse prevention techniques (RP/ABCT), or ABCT with interventions encouraging Alcoholics Anonymous (AA) involvement (AA/ABCT). Couples were followed for 18 months after treatment. Across the 3 treatments, drinkers who provided follow-up data maintained abstinence on almost 80% of days during follow-up, with no differences in drinking or marital happiness outcomes between groups. AA/ABCT participants attended AA meetings more often than ABCT or RP/ABCT participants, and their drinking outcomes were more strongly related to concurrent AA attendance. For the entire sample, AA attendance was positively related to abstinence during follow-up in both concurrent and time-lagged analyses. In the RP/ABCT treatment, attendance at posttreatment booster sessions was related to posttreatment abstinence. Across treatment conditions, marital happiness was related positively to abstinence in concurrent but not time-lagged analyses.
This article is designed to review the representations of alcoholism provided by members of an association of former alcoholics, namely Alcoholics Anonymous (AA), based on partial results from a qualitative survey conducted in the Sapopemba group of AA in a neighborhood on the outskirts of the city of Sao Paulo, Brazil. The article thus analyzes alcoholism from an emic perspective, i.e., how it is conceived and managed by those who acknowledge themselves as being "sick as alcoholics", how they explain the sickness, how they experience it, and how they endeavor to overcome it. The purpose is to present AA and its treatment strategy and to highlight the link made by the association by conceiving of alcoholism as a physical, moral, and spiritual illness.
Project MATCH was the largest and most expensive alcoholism treatment trial ever conducted. The results were disappointing. There were essentially no patient-treatment matches, and three very different treatments produced nearly identical outcomes. These results were interpreted post hoc as evidence that all three treatments were quite effective. We re-analyzed the data in order to estimate effectiveness in relation to quantity of treatment.
This was a secondary analysis of data from a multisite clinical trial of alcohol dependent volunteers (N = 1726) who received outpatient psychosocial therapy. Analyses were confined to the primary outcome variables, percent days abstinent (PDA) and drinks per drinking day (DDD). Overall tests between treatment outcome and treatment quantity were conducted. Next, three specific groups were highlighted. One group consisted of those who dropped out immediately; the second were those who dropped out after receiving only one therapy session, and the third were those who attended 12 therapy sessions.
Overall, a median of only 3% of the drinking outcome at follow-up could be attributed to treatment. However this effect appeared to be present at week one before most of the treatment had been delivered. The zero treatment dropout group showed great improvement, achieving a mean of 72 percent days abstinent at follow-up. Effect size estimates showed that two-thirds to three-fourths of the improvement in the full treatment group was duplicated in the zero treatment group. Outcomes for the one session treatment group were worse than for the zero treatment group, suggesting a patient self selection effect. Nearly all the improvement in all groups had occurred by week one. The full treatment group had improved in PDA by 62% at week one, and the additional 11 therapy sessions added only another 4% improvement.
The results suggest that current psychosocial treatments for alcoholism are not particularly effective. Untreated alcoholics in clinical trials show significant improvement. Most of the improvement which is interpreted as treatment effect is not due to treatment. Part of the remainder appears to be due to selection effects.
Objective: The role of changes in Alcoholics Anonymous (AA) involvement and social networks in relation to abstinence following substance abuse treatment is studied. Specifically, the role of AA and network support for abstinence are examined in relation to their effect on changes in abstinence states between follow-ups. Method: Study sites were 10 representative public and private alcohol treatment programs in a northern California county. A recruitment of 367 men and 288 women seeking treatment were interviewed at intake and re-interviewed I and 3 years later to collect information about alcohol consumption, dependence symptoms, social support for reducing drinking, number of heavy drinkers in the social network and AA involvement. Results: Significant predictors of 90-day abstinence at both the 1- and 3-year follow-up interviews included AA involvement in the last year, percentage of heavy or problem drinkers in the social network, percentage encouraging alcohol reduction and AA-based support for reducing drinking. Panel models estimated an increase in AA participation between 12 and 36 months posttreatment increased the odds of abstinence at 3 years by 35% above those at 12 months. The only significant mediator of AA's effect on abstinence was the number of AA-based contacts supporting reduced drinking, which reduced the magnitude of the relationship by 16%. Conclusions: AA involvement and the type of support received from AA members were consistent contributors to abstinence 3 years following a treatment episode. The enduring effects observed from supportive networks demonstrate the importance of ongoing mechanisms of action that contribute to an abstinent lifestyle.
Objective:
This article examines client drinking and related psychosocial functioning during the course of alcoholism treatment. It focuses on (1) the main effects of the three Project MATCH treatments, (2) the prognostic value of client attributes employed in the matching hypotheses, and (3) the attribute by treatment interaction effects.
Method:
Clients recruited from outpatient settings (n = 952) or from aftercare settings (n = 774) were randomized to one of the following treatments: Motivational Enhancement Therapy (MET), Cognitive Behavioral Therapy (CBT) and Twelve-Step Facilitation (TSF). Alcohol consumption and psychosocial functioning during treatment were assessed at the end of the 12-week treatment phase.
Results:
During the treatment phase, small but statistically significant differences among treatments were found only in the outpatient arm on measures of alcohol consumption and alcohol-related negative consequences. Forty-one percent (41%) of CBT and TSF clients were abstinent or drank moderately without alcohol-related consequences, compared with 28% of MET clients. Tests of 10 a priori primary client-treatment matching hypotheses failed to find any interaction effects that had an impact on drinking throughout the treatment phase.
Conclusions:
In the outpatient setting there appears to be a temporary advantage to assigning individuals to CBT or TSF rather than MET. When there is a need to quickly reduce heavy drinking and alcohol-related consequences, it appears that CBT or TSF should be the treatment of choice.
Aims. (1) To assess the benefits of matching alcohol dependent clients to three treatments, based upon a priori hypotheses involving 11 client attributes; (2) to discuss the implications of these findings and of matching hypotheses previously reported from Project MATCH. Setting and participants. (1) Clients receiving outpatient therapy (N = 952; 72% male); (2) clients receiving aftercare therapy following inpatient or day hospital treatment (N = 774; 80% male). Intervention. Clients were randomly assigned to one of three 12-week, manual-guided, individual treatments: Cognitive Behavioral Coping Skills Therapy (CBT), Motivational Enhancement Therapy (MET) or Twelve-Step Facilitation Therapy (TSF). Design. Two parallel but independent randomized clinical trials were conducted, one with outpatients, one with aftercare clients. Participants were monitored over 15 months including a 1-year post-treatment period. Individual differences in response to treatment were modeled as a latent growth process and evaluated for 17 contrasts specified a priori. Outcome measures were percentage of days abstinent and drinks per drinking day. Findings. Two a priori contrasts demonstrated significant post-treatment attribute by treatment interactions: (1) outpatients high in anger and treated in MET had better post-treatment drinking than in CBT; (2) aftercare clients high in alcohol dependence had better post-treatment outcomes in TSF; low dependence clients did better in CBT. Other matching effects varied over time, while still other interactions were opposite that predicted. Conclusions. (1) Anger and dependence should be considered when assigning clients to these three treatments; (2) considered together with the results of the primary hypotheses, matching effects contrasting these psychotherapies are not robust. Possible explanations include: (a) among the client variables and treatments tested, matching may not be an important factor in determining client outcomes; (b) design issues limited the robustness of effects; and (c) a more fully specified theory of matching is necessary to account for the complexity of the results.
Objective:
To assess the benefits of matching alcohol dependent clients to three different treatments with reference to a variety of client attributes.
Methods:
Two parallel but independent randomized clinical trials were conducted, one with alcohol dependent clients receiving outpatient therapy (N = 952; 72% male) and one with clients receiving aftercare therapy following inpatient or day hospital treatment (N = 774; 80% male). Clients were randomly assigned to one of three 12-week, manual-guided, individually delivered treatments: Cognitive Behavioral Coping Skills Therapy, Motivational Enhancement Therapy or Twelve-Step Facilitation Therapy. Clients were then monitored over a 1-year posttreatment period. Individual differences in response to treatment were modeled as a latent growth process and evaluated for 10 primary matching variables and 16 contrasts specified a priori. The primary outcome measures were percent days abstinent and drinks per drinking day during the 1-year posttreatment period.
Results:
Clients attended on average two-thirds of treatment sessions offered, indicating that substantial amounts of treatment were delivered, and research follow-up rates exceeded 90% of living subjects interviewed at the 1-year posttreatment assessment. Significant and sustained improvements in drinking outcomes were achieved from baseline to 1-year posttreatment by the clients assigned to each of these well-defined and individually delivered psychosocial treatments. There was little difference in outcomes by type of treatment. Only one attribute, psychiatric severity, demonstrated a significant attribute by treatment interaction: In the outpatient study, clients low in psychiatric severity had more abstinent days after 12-step facilitation treatment than after cognitive behavioral therapy. Neither treatment was clearly superior for clients with higher levels of psychiatric severity. Two other attributes showed time-dependent matching effects: motivation among outpatients and meaning-seeking among aftercare clients. Client attributes of motivational readiness, network support for drinking, alcohol involvement, gender, psychiatric severity and sociopathy were prognostic of drinking outcomes over time.
Conclusions:
The findings suggest that psychiatric severity should be considered when assigning clients to outpatient therapies. The lack of other robust matching effects suggests that, aside from psychiatric severity, providers need not take these client characteristics into account when triaging clients to one or the other of these three individually delivered treatment approaches, despite their different treatment philosophies.
Matching treatment modality to patient attribute generally did not improve outcomes in Project MATCH. Untested was whether actual therapist behaviors, irrespective of treatment modality, interacted with patient attributes to improve outcomes. The present study examined whether patient depressive symptoms interacted with therapist focus on painful emotional material to predict the effectiveness of alcohol treatment. Two competing theoretical approaches to treatment effectiveness were considered in light of the results.
A self-report measure of pretreatment depressive symptoms was completed by 141 participants from the Providence Clinical Research Unit of Project MATCH. Therapist focus on emotional material was then judged by independent observer ratings of videotaped treatment sessions. The interaction between these patient and therapy variables was tested as a predictor of percentage of days abstinent (PDA) and percentage of heavy drinking days (PHDD) during treatment and over the first year following treatment.
The interaction between patient depressive symptoms and therapist emotion focus consistently predicted PDA and PHDD both during treatment and over the first year posttreatment. For patients with clinically elevated depressive symptoms, improved drinking outcomes occurred with a low therapist focus on painful emotional material. Conversely, depressed patients had worse drinking outcomes when the therapist had a high focus on emotional material. Therapist behavior did not affect drinking outcomes for patients with subclinical depressive symptoms.
The interaction between depressive symptoms and therapist focus on emotional material was an important predictor of alcohol treatment effectiveness. The results appear to support a theory in which the reduction of patient arousal is a potential mediator of treatment effectiveness. The consistency and robustness of these findings suggest that matching actual therapist behaviors to patient attributes may improve drinking outcomes more than matching based solely on treatment modality.
Aims. (1) To examine the matching hypothesis that Twelve Step Facilitation Therapy (TSF) is more effective than Motivational Enhancement Therapy (MET) for alcohol-dependent clients with networks highly supportive of drinking 3 years following treatment; (2) to test a causal chain providing the rationale for this effect. Design. Outpatients were re-interviewed 3 years following treatment. ANCOVAs tested the matching hypothesis. Setting. Outpatients from five clinical research units distributed across the United States. Participants: Eight hundred and six alcohol-dependent clients. Intervention. Clients were randomly assigned to one of three 12-week, manually-guided, individual treatments: TSF, MET or Cognitive Behavioral Coping Skills Therapy (CBT). Measurements. Network support for drinking prior to treatment, Alcoholics Anonymous (AA) involvement during and following treatment, percentage of days abstinent and drinks per drinking day during months 37-39. Findings. (1) The a priori matching hypothesis that TSF is more effective than MET for clients with networks supportive of drinking was supported at the 3 year follow-up; (2) AA involvement was a partial mediator of this effect; clients with networks supportive of drinking assigned to TSF were more likely to be involved in AA; AA involvement was associated with better 3-year drinking outcomes for such clients. Conclusions. (1) In the long-term TSF may be the treatment of choice for alcohol-dependent clients with networks supportive of drinking; (2) involvement in AA should be given special consideration for clients with networks supportive of drinking, irrespective of the therapy they will receive.
Employee-assistance programs sponsored by companies or labor unions identify workers who abuse alcohol and refer them for care, often to inpatient rehabilitation programs. Yet the effectiveness of inpatient treatment, as compared with a variety of less intensive alternatives, has repeatedly been called into question. In this study, anchored in the work site, we compared the effectiveness of mandatory in-hospital treatment with that of required attendance at the meetings of a self-help group and a choice of treatment options.
We randomly assigned a series of 227 workers newly identified as abusing alcohol to one of three rehabilitation regimens: compulsory inpatient treatment, compulsory attendance at Alcoholics Anonymous (AA) meetings, and a choice of options. Inpatient backup was provided if needed. The groups were compared in terms of 12 job-performance variables and 12 measures of drinking and drug use during a two-year follow-up period.
All three groups improved, and no significant differences were found among the groups in job-related outcome variables. On seven measures of drinking and drug use, however, we found significant differences at several follow-up assessments. The hospital group fared best and that assigned to AA the least well; those allowed to choose a program had intermediate outcomes. Additional inpatient treatment was required significantly more often (P less than 0.0001) by the AA group (63 percent) and the choice group (38 percent) than by subjects assigned to initial treatment in the hospital (23 percent). The differences among the groups were especially pronounced for workers who had used cocaine within six months before study entry. The estimated costs of inpatient treatment for the AA and choice groups averaged only 10 percent less than the costs for the hospital group because of their higher rates of additional treatment.
Even for employed problem drinkers who are not abusing drugs and who have no serious medical problems, an initial referral to AA alone or a choice of programs, although less costly than inpatient care, involves more risk than compulsory inpatient treatment and should be accompanied by close monitoring for signs of incipient relapse.
The first randomized clinical trial on the Hazelden-type of treatment showed that this AA-oriented treatment for alcoholism can result in significant improvement in drinking behavior as compared to a more traditional form of treatment.
One hundred forty-one employed alcoholics were randomized to either Hazelden-type treatment (N= 74) or to traditional-type treatment (N= 67). The treatment groups were highly comparable. The bimonthly follow-up lasted one year.
According to the COPES-questionnaire (short form), the treatment at the Hazelden-type institute was significantly more involving, supportive, encouraging to spontaneity and oriented to personal problems than at the traditional-type institute. In accordance the treatment drop-out rate was 7.9% at Hazelden-type institute and 25.9% at traditional-type institute (p < 0.02). The participation in outpatient treatment was significantly better after the Hazelden-type treatment.
The proportion of those abstinent (admitted ethanol consumption, O g/day; gammaglutamyl transferase, and mean cell volume were normal) was higher at Hazelden-type institute during the last (8–12 months) follow-up period (26.3% vs. 9.8%, p= 0.05). Fourteen percent of the Hazeldon-type institute patients and 1.9% of the traditional-type institute patients stayed abstinent during the whole 1-year follow-up period (p < 0.05). The differences for the corresponding rates for controlled drinking (admitted ethanol consumption less than 40 g/day, GGT, and MCV normal) were in the same direction but did not reach statistical significance. Thus the Hazelden-type treatment obtained better results in 1-year abstinence rate than a more traditional-type treatment.
Reports published since 1976 were reviewed with respect to the characteristics of alcohol-dependent individuals who affiliate with Alcoholics Anonymous (AA). No "AA personality" was identified inasmuch as systematic differences have not been observed between affiliates and nonaffiliates. Evaluation studies were reviewed with regard to data on AA's effectiveness as treatment, leading to several observations. When "alcoholics" participate in AA in addition to professional treatment, their outcome on drinking and other indices is no worse, and may be better, than that of patients who do not involve themselves in AA. AA involvement tends to be associated with relatively high abstinence rates but with only fairly typical total improvement rates. The effectiveness of AA as compared to other treatments for "alcoholism" has yet to be demonstrated. Reliable guidelines have not been established for predicting who among AA members will be successful. An alcohol-involved person's chances of participating in AA are related to the type of drinking outcome achieved. Caution was raised against rigidly referring every alcohol-troubled person to AA.
One hundred and fifty-five subjects who had completed a 4-week residential treatment programme for alcoholism were assigned to one of three aftercare groups: (1) mandatory aftercare in which subjects were contracted to attend four aftercare sessions during the initial 3 months following discharge; (2) voluntary aftercare in which aftercare participation was entirely at the clients' discretion; and (3) no aftercare in which clients were dissuaded from attending aftercare until their fourth month following discharge from inpatient treatment. No differences between groups were found with respect to relapse rate, satisfaction with lifestyle and trait anxiety. In addition, subjects who did not attend aftercare at the treatment centre were not found to make greater use of alternate sources of aftercare (i.e. Alcoholics Anonymous (AA), physicians and other treatment resources). Despite the fact that aftercare participation was not found to be related to outcome, an apparent demand for aftercare was evidenced. In that regard, 66% of the subjects in the Voluntary Group requested aftercare.
It is suggested that the results of this study are consistent with the body of literature which contends that there is no advantage to extended therapy in the treatment of alcoholism. Furthermore, the possibility is raised that previous research efforts that have found a positive relationship between aftercare and outcome may have been confounded ty the issue of ‘patient compliance’ with the terms of treatment. That is, subjects who comply with the terms of treatment tend towards better outcomes irrespective of whether the terms of treatment call for aftercare or not. In conclusion, the authors recommend greater individualized aftercare planning for alcoholics and suggest a greater emphasis on ‘processing relapses’.
The Addiction Severity Index (ASI) is a structured clinical interview developed to fill the need for a reliable, valid, and standardized diagnostic and evaluative instrument in the field of alcohol and drug abuse. The ASI may be administered by a technician in 20 to 30 minutes producing 10-point problem severity ratings in each of six areas commonly affected by addiction. Analyses of these problem severity ratings on 524 male veteran alcoholics and drug addicts showed them to be highly reliable and valid. Correlational analyses using the severity ratings indicated considerable independence between the problem areas, suggesting that the treatment problems of patients are not necessarily related to the severity of their chemical abuse. Cluster analyses using these ratings revealed the presence of six subgroups having distinctly different patterns of treatment problems. The authors suggest the use of the ASI to match patients with treatments and to promote greater comparability of research findings.
Of a sample of 100 patients on an inpatient alcohol rehab unit, 50 were assigned to a weekly group therapy session in the aftercare clinic. Those inpatients with aftercare clinic exposure prior to discharge were more likely to return for aftercare. In a second study of 100 inpatients the effect of having a counselor who would continue to follow them in aftercare was explored. Half the sample had a counselor whose primary assignment was in the aftercare clinic and thus could work with them on a continuing basis. The other half had a counselor whose primary assignment was on the inpatient unit and would not be able to continue with them. Counselor continuity had no impact on aftercare follow through.
Reviews of research on Alcoholics Anonymous (AA) have speculated how findings may differ when grouped by client and study characteristics. A meta-analytic review by Emrick et al. in 1993 provided empirical support for this concern but did not explore its implications. This review divided results of AA affiliation and outcome research by sample origin and global rating of study quality. The review also examined the statistical power of studies on AA.
Meta-analytic procedures were used to summarize the findings of 74 studies that examined AA affiliation and outcome. Results were divided by whether samples were drawn from outpatient or inpatient settings and a global rating of study quality that jointly considered use of subject selection and assignment, reliability of measurement and corroboration of self-report. Efficacy of dividing study results was examined by changes in magnitude of correlations and unexplained variance.
AA participation and drinking outcomes were more strongly related in outpatient samples, and better designed studies were more likely to report positive psychosocial outcomes related to AA attendance. In general, AA studies lacked sufficient statistical power to detect relationships of interest.
AA experiences and outcomes are heterogeneous, and it makes little sense to seek omnibus profiles of AA affiliates or outcomes. Well-designed studies with large outpatient samples may afford the best opportunity to detect predictors and effects of AA involvement.
Results are presented of a randomized field trial comparing two aftercare regimes, namely individual versus group delivery of a structured relapse prevention approach. Two addictions treatment programs (one a 12-Step 26-day residential program, the other an evening group counselling program) implemented structured relapse prevention in either group or individual format as part of the first three months of aftercare. Process measures (e.g. attendance, client satisfaction) indicated that both group and individual formats were delivered very successfully at both sites. Follow-up rate at 12 months across both programs was 74%, and drinking and drug use at the 12-month follow-up was substantially less than use at entry into treatment. However, there were no significant differences in outcomes between individual and group delivery on any of the alcohol or drug use measures. Only one psychosocial outcome measure (social support from friends at 12-month follow-up) showed a significant difference for format and it favored the group format. These findings suggest some important directions for future research.
The purpose of this study is to examine implementation of a randomized clinical trial and within treatment behavior when AA is included as an element of treatment. Special attention is given to the measurement of compliance, use of treatment skills, and the nature and extent of involvement with AA during the active phase of treatment.
Subjects, 90 male alcoholics and their female partners seeking conjoint, outpatient behavioral alcoholism treatment, were randomly assigned to one of three treatments: alcohol-focused behavioral marital therapy (ABMT), ABMT plus AA/Alanon (AA/ABMT), or ABMT plus relapse prevention (RP/ABMT). Within treatment data are reported for the 68 couples who completed at least five treatment sessions. Measures included: treatment attrition, number of treatment sessions, attendance at AA and Alanon, use of AA and Alanon skills, compliance with homework assignments and drinking during treatment.
Several aspects of within treatment behavior were examined: (1) Attrition: There was no differential attrition across treatment conditions, with 24.4% of couples discontinuing treatment prior to the fifth session. (2) AA and Alanon attendance: Subjects in the AA/ABMT treatment were more likely to attend AA (91.7% attended at least one AA meeting; 58.3% attended at least one Alanon meeting) than were subjects in the other treatment conditions (18% attended at least one AA meeting and 14% at least one Alanon meeting). Subjects in the AA/ABMT condition attended significantly more AA and Alanon meetings than did subjects in the other treatment conditions. (3) Homework compliance: Subjects generally showed no differences in compliance with homework assignments, but spouses in the AA/ABMT condition completed less condition-specific homework (37.2%, versus 67.8% for the RP/ABMT spouses) because of low utilization of Alanon. (4) Use of AA-related skills: Subjects reported using AA-related skills more frequently in the AA/ABMT condition than in the other treatment conditions. (5) Patterns of attendance: Analyses of AA attendance during treatment revealed three patterns: positive attendance, characterized by regular AA attendance or increasing use of AA across treatment; negative attendance, characterized by decreased AA attendance over time; and nonattendance, characterized by none or infrequent and erratic attendance.
Randomized clinical trials can be used to study AA. Use of multiple measures of treatment compliance and examination of patterns of AA utilization use over time provide more complex views of the patterns of involvement with AA than do simple descriptive reports of attendance.
The comparative effectiveness of 12-step and cognitive-behavioral (C-B) models of substance abuse treatment was examined among 3,018 patients from 15 programs at U.S. Department of Veterans Affairs Medical Centers. Across program types, participants showed significant improvements in functioning from treatment admission to a 1-year follow-up. Although 12-step patients were somewhat more likely to be abstinent at the 1-year follow-up, 12-step, C-B, and combined 12-Step-C-B treatment programs were equally effective in reducing substance use and improving most other areas of functioning. The finding of equal effectiveness was consistent over several treatment subgroups: Patients attending the "purest" 12-step and C-B treatment programs, and patients who had received the "full dose" of treatment. Also, patients with only substance abuse diagnoses, those with concomitant psychiatric diagnoses, and patients who were mandated to treatment showed similar improvement at the 1-year follow-up, regardless of type of treatment received. These data provide important new evidence supporting the effectiveness of 12-step treatment.
This article reviews the outcome (usually abstinence at 12 months) of 21 controlled studies of AA, with emphasis on methodological quality. Severe selection biases compromised all quasi-experiments. Randomized studies yielded worse results for AA than nonrandomized studies, but were biased by selection of coerced subjects. Attending conventional AA meetings was worse than no treatment or alternative treatment; residential AA-modeled treatments performed no better or worse than alternatives; and several components of AA seemed supported (recovering alcoholics as therapists, peer-led self-help therapy groups, teaching the Twelve-Step process, and doing an honest inventory).
Despite enthusiasm for the potential of matching patients to alcohol treatments to improve outcomes, consistent findings have not emerged. This review considers the extent to which methodological factors may account for the pattern of findings from research on Patient x Alcohol Treatment interactions.
We focused on 55 studies that compared more than one type of alcohol treatment and included formal statistical tests for interactions. We examined four predictors of the number of significant interactions found in the 55 studies: (1) the number of statistical tests for interactions conducted, (2) the average number of participants, (3) whether or not participants were randomized to treatment and (4) the proportion of tested interactions that were hypothesis- or rationale-driven, as opposed to exploratory.
Only the number of statistical tests for interactions predicted the number of patient-treatment interactions identified per study (zero-order r = 0.47; r2 = 0.22). A substantial number of tests for interactions (43) was conducted, on average, per study. Only a minority of the studies (33%) included enough participants to have a reasonable probability (0.80) of identifying a medium-sized matching effect.
Drawing general conclusions regarding matching patients to alcohol treatments is hampered because Type I error has contributed to the matches identified, studies in this area are often underpowered, and the combinations of patient and treatment variables that have been tested are few relative to the numerous possible combinations. To be productive, future research will need to focus on patients at the extremes of matching dimensions and on distinct treatments. (J Stud. Alcohol 62: 62-73, 2001)
This paper reports the long-term recovery rate among 100 alcoholic doctors over a 21-year period. Included are 20 doctors who relapsed and re-recovered, 10 who died of non-alcohol related causes and eight who died of alcohol-linked causes. Also reported are abstinence, attendance at self-help group meetings, mortality and employment.
Selected doctors were the first 100 consecutive alcoholic doctors to become members of the North West Doctors and Dentists Group (NWDDG) between 1980 and 1988. Information sources combine prospective data obtained from each doctor at the time of first contact with the results of questionnaires distributed in 1988 and 2001 and continuing prospective reporting of mortality by relatives.
There is a 9% incidence of oral or oesophagopharyngeal cancer. Reported mortality, mostly by relatives, revealed that 24 doctors died directly of their alcoholism. We observed a 73% recovery rate for a 17-year average duration, over a 21-year period. Comparison of recovery with abstinence showed a strong correlation. For the first 6 months of recovery, there was also a strong relationship between recovery and attending meetings of self-help groups. This relationship is not sustained in the long term, though 14 doctors with an average recovery of 20 years still attend meetings regularly. Of 56 doctors currently known to have survived, 29 have retired and 27 are still working as doctors. Three doctors have been drinking normally for an average of 17 years.
This study sought to examine the effectiveness of a "standard" outpatient alcoholism treatment (ST) program. An outpatient alcoholism treatment as it is commonly practiced in the US (with group and individual therapy, and an emphasis on Alcoholics Anonymous [AA]), was compared with a minimal treatment (MT) approach (weekly alcohol education movies). At 6 months, ST patients surpassed those in MT in terms of complete abstinence, reduction in amount of alcohol consumed, length of sobriety at follow-up, improvement in employment status, number of AA meetings attended, and lower initial drop-out. It is concluded that a ST approach is more helpful than MT in treating severely alcohol-dependent individuals who have not been able to cut down drinking on their own. Those already drinking less appeared to be helped by MT.
The aim of this study was to compare initially untreated women and men problem drinkers on help-utilization and outcomes over 8 years.
At the time of the 8-year follow-up, individuals (N=466, 49% female) had self-selected into four groups: no help, Alcoholics Anonymous (AA) only, formal treatment only or formal treatment plus AA.
At baseline and 1, 3 and 8 years later, participants completed measures of drinking and functioning.
Women were generally worse off than men on baseline drinking and functioning indices. In keeping with their poorer baseline status, women were more likely to participate in AA, and had longer in-patient stays during the next year. When women's baseline status was controlled, women had better outcomes than did men at 1 and 8 years. Generally, women and men did not differ on the extent to which obtaining help, or a particular type of help, was related to improved outcomes. Regarding drinking outcomes, women benefited more than did men from more AA attendance during years 2-8 of follow-up.
The results suggest that although alcoholism interventions were designed primarily for men, they are currently delivered in ways that are also useful to women. Problem-drinking women appear to benefit from sustained participation in AA, which emphasizes bonding with supportive peers to maintain abstinence.
The role of changes in Alcoholics Anonymous (AA) involvement and social networks in relation to abstinence following substance abuse treatment is studied. Specifically, the role of AA and network support for abstinence are examined in relation to their effect on changes in abstinence states between follow-ups.
Study sites were 10 representative public and private alcohol treatment programs in a northern California county. A recruitment of 367 men and 288 women seeking treatment were interviewed at intake and re-interviewed 1 and 3 years later to collect information about alcohol consumption, dependence symptoms, social support for reducing drinking, number of heavy drinkers in the social network and AA involvement.
Significant predictors of 90-day abstinence at both the 1- and 3-year follow-up interviews included AA involvement in the last year, percentage of heavy or problem drinkers in the social network, percentage encouraging alcohol reduction and AA-based support for reducing drinking. Panel models estimated an increase in AA participation between 12 and 36 months posttreatment increased the odds of abstinence at 3 years by 35% above those at 12 months. The only significant mediator of AA's effect on abstinence was the number of AA-based contacts supporting reduced drinking, which reduced the magnitude of the relationship by 16%.
AA involvement and the type of support received from AA members were consistent contributors to abstinence 3 years following a treatment episode. The enduring effects observed from supportive networks demonstrate the importance of ongoing mechanisms of action that contribute to an abstinent lifestyle.
The impact of disease on health-related quality of life is now well recognized, as is the importance of this variable as a measure of treatment efficacy.
Patients from five European countries were enrolled in an open, multicenter, prospective study designed to observe outcome in dependent drinkers treated for 6 months with acamprosate and psychosocial support. Version 1 of the 36-item Short Form Health Profile (SF-36v1) questionnaire was administered at inclusion and at 3 and 6 months. Responses were described as handicaps compared with an appropriately matched, healthy reference population. One-way fixed ANOVA and simultaneous stepwise linear regression analysis were used to identify potential predictors of quality of life at baseline and after treatment.
Baseline SF-36v1 data were obtained from 1216 patients (mean age, 43 +/- 9 years; 77% male). Mean values for all SF-36v1 dimensions were significantly lower in the patient population than in the normative reference population; the most important deficits were observed in physical and emotional role limitations and in social functioning. The most important predictors of baseline quality of life were severity of alcohol dependence, employment status, psychiatric history, quantity and frequency of alcohol consumption, attendance at Alcoholics Anonymous, global alcohol health status, age, gender, and education. SF-36v1 data were obtained from 686 patients at 3 months and from 497 at 6 months. Significant improvements were observed in all SF-36v1 dimensional and summary scores after 3 months of treatment (p < 0.001); further marginal improvements were observed between 3 and 6 months. The most important predictors of quality of life following treatment were the SF-36v1 profile at baseline, followed by abstinence duration; patients who completed the trial and remained abstinent throughout showed the greatest improvement.
Health-related quality of life is severly impaired in dependent drinkers. Treatment with acamprosate and psychosocial support, by promoting abstinence, improves the quality of life profile to levels comparable to those observed in healthy individuals.
Influences on seeking help from professional alcohol treatment and from Alcoholics Anonymous (AA) were investigated using problem drinkers (N = 167) with different help-seeking experiences (no assistance, AA only, or treatment plus AA) and current drinking statuses (sustained abstinence for > 2 years or active problem drinking). Depending on their help-seeking experiences, participants rated barriers to or reasons for seeking help from treatment and AA, which were factor analyzed. Common impediments to help-seeking included privacy concerns and participants' beliefs that they could solve their problem on their own and that it was not serious enough to seek help. Common reasons for help-seeking included social and other functional problems related to drinking. There were also influences unique to treatment (e.g., cost) and to AA (e.g., group format). Help-seeking factors did not vary by drinking status. The implications for increasing help-seeking among problem drinkers are discussed.
This expert consensus statement reviews evidence on the effectiveness of drug and alcohol self-help groups and presents potential implications for clinicians, treatment program managers and policymakers. Because longitudinal studies associate self-help group involvement with reduced substance use, improved psychosocial functioning, and lessened health care costs, there are humane and practical reasons to develop self-help group supportive policies. Policies described here that could be implemented by clinicians and program managers include making greater use of empirically-validated self-help group referral methods in both specialty and non-specialty treatment settings and developing a menu of locally available self-help group options that are responsive to client's needs, preferences, and cultural background. The workgroup also offered possible self-help supportive policy options (e.g., supporting self-help clearinghouses) for state and federal decision makers. Implementing such policies could strengthen alcohol and drug self-help organizations, and thereby enhance the national response to the serious public health problem of substance abuse.
Primary care providers need practical methods for managing patients who screen positive for at-risk drinking. We evaluated whether scores on brief alcohol screening questionnaires and patient reports of prior alcohol treatment reflect the severity of recent problems due to drinking.
Veterans Affairs general medicine outpatients who screened positive for at-risk drinking were mailed questionnaires that included the Alcohol Use Disorders Identification Test (AUDIT) and a question about prior alcohol treatment or participation in Alcoholics Anonymous ("previously treated"). AUDIT questions 4 through 10 were used to measure past-year problems due to drinking (PYPD). Cross-sectional analyses compared the prevalence of PYPD and mean Past-Year AUDIT Symptom Scores (0-28 points) among at-risk drinkers with varying scores on the CAGE (0-4) and AUDIT-C (0-12) and varying treatment histories.
Of 7861 male at-risk drinkers who completed questionnaires, 33.9% reported PYPD. AUDIT-C scores were more strongly associated with Past-Year AUDIT Symptom Scores than the CAGE (p < 0.0005). The prevalence of PYPD increased from 33% to 46% over the range of positive CAGE scores but from 29% to 77% over the range of positive AUDIT-C scores. Among subgroups of at-risk drinkers with the same screening scores, patients who reported prior treatment were more likely than never-treated at-risk drinkers to report PYPD and had higher mean Past-Year AUDIT Symptom Scores (p < 0.0005). We propose a simple method of risk-stratifying patients using AUDIT-C scores and alcohol treatment histories.
AUDIT-C scores combined with one question about prior alcohol treatment can help estimate the severity of PYPD among male Veterans Affairs outpatients.
The helper therapy principle suggests that, within mutual-help groups, those who help others help themselves. The current study examines whether clients in treatment for alcohol and drug problems benefit from helping others, and how helping relates to 12-step involvement.
Longitudinal treatment outcome.
An ethnically diverse community sample of 279 alcohol- and/or drug-dependent individuals (162 males, 117 females) was recruited through advertisement and treatment referral from Northern California Bay Area communities.
were treated at one of four day-treatment programs.
A helping checklist measured the amount of time participants spent, during treatment, helping others by sharing experiences, explaining how to get help and giving advice on housing and employment. Measures of 12-step involvement and substance use outcomes were administered at baseline and a 6 month follow-up.
Helping and 12-step involvement emerged as important and related predictors of treatment outcomes. In the general sample, total abstinence at follow-up was strongly and positively predicted by 12-step involvement at follow-up, but not by helping during treatment; still, helping positively predicted subsequent 12-step involvement. Among individuals still drinking at follow-up, helping during treatment predicted a lower probability of binge drinking, whereas effects for 12-step involvement proved inconsistent.
Findings support the helper therapy principle and clarify the process of 12-step affiliation.
This study examined the influence of self-selection, as reflected in alcohol-related functioning, on the duration of professional treatment and Alcoholics Anonymous (AA), and the influence of social causation, as reflected in the duration of treatment and AA, on alcohol-related outcomes. A sample of alcoholic individuals was surveyed at baseline and 1, 3, and 8 years later. At each point, participants completed an inventory that assessed participation in treatment and AA since the last assessment and alcohol-related functioning. There were divergent processes of self-selection and social causation with respect to the duration of participation in professional treatment and AA. Individuals with more severe alcohol-related problems obtained longer episodes of professional treatment, but this self-selection process was much less evident for AA. Longer participation in professional treatment in the first year predicted better alcohol-related outcomes; however, the duration of subsequent treatment was not associated with better subsequent outcomes. In contrast, longer participation in AA consistently predicted better subsequent alcohol-related outcomes. These findings are consistent with a need-based model of professional treatment, in which more treatment is selected by and allocated to individuals with more severe problems, and an egalitarian model of self-help, in which need factors play little or no role in continued participation.
An increasing body of research evidence supports the use of 12-step program affiliation as an effective adjunct and aftercare for formal treatment. Recently, three brief (9- or 10-item) measures of affiliation have been developed. However, the brief scales are difficult to interpret, and the question of exactly what is affiliation (or disaffiliation) remains unclear. This analysis examines the question of what is the essence of affiliation vs. disaffiliation. Data from the Project MATCH 1-year posttreatment Alcoholics Anonymous Involvement (AAI) scale (N=1506) are used to identify the most salient items of Alcoholics Anonymous (AA) affiliation predicting 1-year posttreatment drinking outcomes. Analysis using stepwise regression suggests that a three-item solution can explain a similar amount of variance in the proportion of days abstinent in months 9 through 12 posttreatment, as does using the nine items. These three "core items predicting recovery" include AA attendance, sum of steps completed, and identifying self as an AA member. As an affiliation composite scale, these three items are easier to interpret and administer than the full AAI scale, and when combined, possess adequate reliability (alpha=0.72).
The present study aimed to determine whether alcoholics who attend self-help groups experience fewer deaths than those who do not. Subjects were patients from the Alcoholism Treatment Program (ATP) of Matsuzawa hospital. A cohort of alcoholic patients recruited into a prospective study was followed from April 1994 to March 1999. A total of 469 alcoholic patients met the International Classification of Diseases (10th edition) criteria for alcohol dependency. Of these, 94 patients refused to participate in the study, leaving a total of 375 participants. After discharge from the ATP and a complete explanation of the present study, subjects decided whether to attend a self-help group (SHG) or not. The SHG comprised 208 subjects, and the non-self-help group (NSHG) comprised 167 subjects. Outcomes were evaluated with regard to death during follow-up for a mean of 2.4 years. Death was ascertained through the records of the Setagaya Department of Health and Welfare center, Matsuzawa hospital and other hospitals, and through personal contact with informants, relatives, and significant others of subjects. Deaths were confirmed for 47 NSHG subjects and only five SHG subjects. NSHG displayed a significantly decreased cumulative survival compared with SHG (P < 0.0001). Cox proportion hazard analysis was used to examine variables that may help to predict mortality among alcoholics. Alcoholics who attended self-help groups differed from those who did not, with regard to mortality experience. Attending a self-help group represented the most important predictor of prognosis for alcoholics.
The provision of prescribed heroin to chronic heroin-dependent individuals failing other treatments has been supported during the last 70 years on the ground that the first goal of interventions on drug users is to keep them in treatment to protect them from criminal activities and to promote social integration. To assess heroin prescription effectiveness, we conducted a Cochrane systematic review of all relevant randomized controlled trials. We searched MEDLINE, EMBASE, CINAHL, and the Cochrane Library and contacted leading researchers for ongoing studies. We found 19 eligible studies, of which 4 met our inclusion criteria (577 patients). In 1 study, patients in the heroin arm remained in treatment longer than those in the methadone arm (n = 96, RR = 2.82, 95% CI = 1.70-4.68); in 2 studies, there was no difference; and in 1 study, patients given heroin left the study earlier than those given methadone (n = 235, RR = 0.79, 95% CI = 0.68-0.90). Heroin was more effective than methadone in refraining people from using street heroin in 2 studies (n = 96, RR = 1.10, 95% CI = 0.79-1.53; n = 51, RR = 0.33, 95% CI = 0.15-0.72). In 1 study, heroin reduced the risk of being charged (RR = 0.32, 95% CI = 0.14-0.78); 2 studies showed no difference, and another 2 studies adopted a multidomain outcome enclosing criminal offense and social functioning and found improvements with heroin + methadone over methadone only. It is unclear if heroin attracts people in treatment; those in treatment use less street heroin and are likely to have less criminal activities. This review systematizes and compares studies showing some inconsistencies between their aims, their adopted outcomes, and their conclusions drawn from results.