Transcript Slide 1

Evidence for twelve step
facilitation in the medical
literature
Jonathan Chick
HLO’s meeting, York, March 2014
How to show that AA is effective?
Health commissioners expect positive
results of RCTs (randomised, controlled,
studies)
- “perhaps the people who do well in AA
would have done well anyhow because
they are ‘well motivated’”
Evidence for AA (1)
True randomised controlled study
impossible, but:
• Many follow-up studies show that stable
recovery is associated with regular
attendance at AA / NA
Enhanced friendship networks and active coping
mediate the effect of self-help groups on substance
abuse
– 2,337 male veterans treated for substance
abuse
– The majority of participants became involved
in self-help groups after inpatient treatment
– group involvement predicted reduced
substance use at 1-year follow-up
– enhanced friendship networks and increased
active coping responses appeared to mediate
these effects
Humphreys et al . 1999 Ann Behav Med21:54-60
Attendance at Alcoholics Anonymous meetings after
inpatient treatment is related to better outcomes; a
6-month follow-up study.
(Gossop et al National Addiction Centre, Institute of Psychiatry, London)
Participants interviewed at admission (within 5 days of entry), and (80%) 6
months following departure. N= 150 patients in an inpatient alcohol
treatment programme who met ICD-10 criteria for alcohol dependence.
RESULTS:
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.
Correlates of Recovery from Alcohol Dependence: A Prospective
Study Over a 3-Year Follow-Up Interval
Dawson et al.
Online Alc Clin Exp Res: 6 FEB 2012
Wave 1: Alcohol dependence (n = 1,172)
Wave 2: Abstinent recovery significantly
associated with Black/Asian/Hispanic
race/ethnicity, children <1 year of age in the
household at baseline, attending religious
services greater than or equal to weekly at
follow-up, and having initiated help-seeking
that comprised/included 12-step participation
within <3 years prior to baseline.
Evidence for AA (2)
RCTs of ‘Facilitation’ by healthcare
professionals
Project MATCH Research group
Addiction 1997;92:1671-98
Out-patients N=952
Aftercare following in-patient stay N=774
Random allocation to either:
12 sessions cognitive behavioral therapyCBT
or 12 sessions of twelve-step facilitationTSF
or 4 sessions of motivational enhancement
therapy - MET
PROJECT MATCH: 1 year outcome
Time to First Drink, and Time to 3 Successive
Heavy Drinking Days, better in TSF than CBT
or MET
• Highly dependent did best in TSF (low
dependence better in CBT)
At 3 years, still slight advantage on some
measures to TSF
(Only 40% of TSF patients regularly attended AA)
Randomised Controlled trial of intensive referral to 12 step self help
groups: Timko and DeBenedetti, Drug Alc Depend 2007; 90:270-9
N=345 ; 96% had previous addiction treatment.
Random assignment to a standard referral or an intensive referral-to-self-help
condition
Intensive referral: counselors linked patients to 12-step volunteers and
checked on meeting attendance.
One-year follow-up (93%).
RESULTS: Compared with patients who received standard referral, patients
who received intensive referral were more likely to attend and be involved
with 12-step groups during both the first and second six-month follow-up
periods, and improved more on alcohol and drug use outcomes over the
year.
During both follow-up periods, patients in intensive referral were more likely to
attend at least one meeting per week (70% versus 61%, p=.049) and had
higher involvement (mean=4.9 versus 3.7, p=.021) and abstinence rates
(51% versus 41%, p=.048).
Twelve-step involvement mediated the association between referral condition
and alcohol and drug outcomes, and was associated with better outcomes
above and beyond group attendance
Dual diagnosis (i.e. addiction +
serious mental illness)
Bogenschutz et al
J Subst Abuse Treat. 2014 46:403-11.
“12-step facilitation for the dual
diagnosed: A randomized clinical trial”
No advantage in terms of alcohol/drug use
(but more meetings -> better outcomes)
Twelve Step Facilitation (TSF) in cocaine-dependent individuals
maintained on methadone: a randomized placebo-controlled trial
Carroll et al
.
Cocaine used reduced with TSF
Drug Alcohol Depend. 2012 126:224-31
TSF as effective in cocaine addiction as as giving vouchers
for clear urines cocaine (up to 12 months)
• Contingency management with
community reinforcement approach or
twelve-step facilitation drug counseling
for cocaine dependent pregnant women
or women with young children.
• Schottenfeld et al
• Drug Alcohol Depend. 2011 Oct
1;118(1):48-55.
J Subst Abuse Treat. 2009 Oct;37(3):228-39. Epub 2009 Apr 1.
Effectiveness of Making Alcoholics Anonymous Easier: a group format 12-step facilitation
approach.
Kaskutas LA, Subbaraman MS, Witbrodt J, Zemore SE.
• Making Alcoholics Anonymous [AA] Easier (MAAEZ ), a manualguided intervention designed to help clients connect with individuals
encountered in AA, was tested using an "OFF/ON" design (n = 508).
• MAAEZ effectiveness was determined by comparing abstinence
rates of participants recruited during ON and OFF conditions and by
studying the effect of the number of MAAEZ sessions attended.
• At 12 months, more clients in the ON condition (vs. OFF) reported
past 30-day abstinence from alcohol (p = .012), drugs (p = .009),
and both alcohol and drugs (p = .045). In multivariate analyses, ON
condition participants had significantly increased odds of
abstinence from alcohol (odds ratio [OR] = 1.85) and from
drugs (OR = 2.21);
• abstinence odds also increased significantly for each additional
MAAEZ session received. MAAEZ appeared especially effective for
those with more prior AA exposure, severe psychiatric problems,
and atheists/agnostics.
Social relationships predict not just mental health and wellbeing
but also ‘hard’ impacts like mortality
Meta analysis: comparative odds of decreased mortality
LGID: Wellbeing - why bother?
UNCLASSIFIED
Source:
Holt-Lundstad et al 2010
social
relationships
have as
great an
impact as
smoking
cessation,
and more
than physical
activity and
issues to
address
obesity
15
NICE 2011
(National Institute for Health and Clinical Excellence)
Diagnosis, assessment and management of harmful
drinking and alcohol dependence
“For all people seeking help for alcohol misuse:
• give information on the value and availability of
community support networks and self-help groups (for
example, Alcoholics Anonymous or SMART Recovery)
and
• help them to participate in community support networks
and self-help groups by encouraging them to go to
meetings and arranging support so that they can attend”