12-step facilitation for the dually diagnosed: a randomized clinical trial

The impact of spiritual well-being and social support on substance use treatment outcomes within a sample of predominantly Black/African American adults

INTRO

Substance use and associated problems often return following treatment for substance use disorder (SUD), which disproportionally impact Black/African American (AA) individuals. Social support and spiritual well-being are sources of recovery capital identified as particularly important among Black/AA adults. Social support and spiritual well-being are also posited mechanisms in 12-step; thus, this study tested the effects of social support and spiritual well-being on substance use outcomes over time, distinct from 12-step involvement, among Black/AA adults post-SUD treatment. The study hypothesized that social support and spiritual well-being would demonstrate significant interactions with time, respectively, on substance use frequency and substance use consequences, above the effect of 12-step involvement.

METHOD

The study drew data from a study of 262 adults (95.4 % Black/AA) entering residential SUD treatment (NCT#01189552). Assessments were completed at pretreatment and at 3-, 6-, and 12-months posttreatment. Two generalized linear mixed models (GLMM) tested the effects of social support and spiritual well-being, above the effect of 12-step involvement, on substance use frequency and substance use consequences over the course of 12-months posttreatment.

RESULTS

Higher spiritual well-being predicted significantly less frequent substance use during recovery (β = 0.00, p = .03). Greater 12-step involvement predicted significantly fewer substance use consequences during recovery (β = 0.00, p = .02). In post hoc analyses the effect of spiritual well-being and 12-step involvement dissipated by 3.5- and 6.6-months posttreatment, respectively. The study found no significant effects of social support over time.

DISCUSSION

Spiritual well-being and 12-step involvement are associated with lower substance use and substance use consequences, respectively, in the early months of posttreatment recovery among Black/AA adults. These findings contribute to the growing recovery capital literature informing paths to recovery and sources of support outside of 12-step affiliation. However, these effects diminish over time.

Efficacy of 12-step mutual-help groups other than Alcoholics Anonymous: a systematic review and meta-analysis

This paper offers a systematic review of quantitative and qualitative studies on the main twelve-step mutual-help (TSMH) groups (excluding Alcoholics Anonymous) and four meta-analyses exploring the correlation between (i) duration or involvement in TSMH groups and; (ii) severity of symptoms or quality of life. Systematic review was conducted following PRISMA guidelines. Searches of databases (MEDLINE, PsychInfo), a register (ClinicalTrials) and citations were conducted, from inception through November 01 2022. Fifty five articles were included (24 quantitative, 27 qualitative, 4 mixed-methods), corresponding to 47 distinctive studies. 68% of these studies were conducted in North America, 17% in Middle East, 11% in the European Union and 4% in Australia. The most studied TSMH group were Gamblers Anonymous (28% of the 47 studies), Narcotics Anonymous (26%), Double Trouble in Recovery (15%), Overeaters Anonymous (19%) and TSMH groups for compulsive sexual behaviors (11%). The four meta-analyses pooled data from 9 studies. Pooled mean age ranged from 36.5 to 40.5. 80-81% of participants were male. TSMH attendance and involvement were negatively correlated with severity of symptoms (high and medium levels of evidence) and positively correlated with quality of life (low levels of evidence). Twenty-one qualitative papers reported factors influencing recovery: Social (n = 15), emotional (n = 9), spiritual (n = 8), self-identification or psychological (n = 6) factors. Review provides characteristics of TSMH groups others than Alcoholics Anonymous, with implications for both research and healthcare practice. The perspective to implement TSMH groups targeting ontological addiction, at the root of all addiction, is discussed.Protocol registration: Prospero registration number: CRD42022342605.

Social support and depressive symptoms: exploring stigma and self-efficacy in a moderated mediation model

BACKGROUND

Although some psychological processes, such as stigma and self-efficacy, affect the complicated relationship between social support and depressive symptoms, few studies explored a similar psychological mechanism among individuals with substance use disorders (SUDs). Hence, this research investigates the mediating effects of stigma and the moderating effects of self-efficacy among the psychological mechanism that social support affects depressive symptoms.

METHODS

The study included 1040 Chinese participants with SUDs and completed a series of self-report questionnaires. R software was used to organize and clean up data sets and analyze mediation and moderation effects.

RESULTS

The result showed that stigma partially mediated depressive symptoms, while self-efficacy moderated this relationship. More specifically, less social support increased depression symptoms by bringing about higher stigma. Besides, subjects with higher self-efficacy are less susceptible to stigma and therefore have mild depressive symptoms. Furthermore, clinical and theoretical implications are discussed in our study.

CONCLUSIONS

Chinese SUDs patients' depressive symptoms were indirectly affected by perceived social support via stigma and less affected by stigma with improved self-efficacy. The theoretical and practical implications of these results are discussed.

Dropout Rates in Psychosocial Interventions for People With Both Severe Mental Illness and Substance Misuse: A Systematic Review and Meta-Analysis

INTRODUCTION

Over the years, many psychosocial interventions for individual having both a psychotic spectrum disorder and a substance use disorder diagnoses have been developed and studied. However, there is a high dropout rate among this clinical population.

OBJECTIVES

This meta-analysis aims to replicate a previous meta-analysis on the effects of psychosocial treatment for dual disorders, while including and determining the dropout rates in those type of interventions.

METHOD

Based on a Cochrane systematic review conducted in 2019, we conducted a meta-analysis including 40 randomized clinical trials on psychosocial treatment among persons suffering from schizophrenia spectrum disorder and substance use disorder.

RESULTS

A dropout rate of 27,2% was obtained. Stimulants use significantly affected dropout rates. Age, gender, diagnosis, alcohol and cannabis abuse, and duration of treatment did not affect dropout rates.

CONCLUSION

The 27,2% rate of dropout from psychosocial treatment highlights the need to engage participants having a dual diagnosis from the start by focusing on therapeutic alliance and motivation for treatment.

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

BACKGROUND

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

OBJECTIVES

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

RESULTS

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

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Strategies to improve treatment utilization for substance use disorders: A systematic review of intervention studies

BACKGROUND

Many people who need specialty treatment for substance use disorders (SUDs) do not receive it. Clinical interventions could increase treatment utilization but are not routinely used. This systematic review aimed to describe clinical interventions that may increase SUD specialty treatment utilization (i.e., treatment initiation, attendance, meaningful engagement) and to determine which intervention(s) most consistently increase treatment utilization.

METHODS

We conducted a systematic review of clinical intervention studies (published in English between 2000 and 2017) reporting outcomes relevant to specialty SUD treatment utilization. Outcomes were treatment initiation, attendance, and meaningful engagement. Risk of bias was assessed using Cochrane guidelines and randomized controlled trials (RCTs) with bias scores < 3 were included in a synthesis of results. Proportions of positive to negative utilization outcomes were calculated for each low-bias RCT; studies with 50% positive outcomes or more were considered "majority-positive". Studies were categorized by theory-based approach.

RESULTS

Twenty-three RCTs had low risk of bias and were synthesized. Among intervention types with two or more studies, cognitive-behavioral (100% majority-positive) and coordinated care (67% majority-positive) interventions were most likely to increase treatment initiation, while 12-step promotion interventions were most likely to increase treatment attendance (50% majority-positive). One study (12-step promotion) measured meaningful engagement, with majority-positive outcomes.

CONCLUSIONS

A systematic review and narrative synthesis of clinical interventions promoting specialty SUD treatment utilization provided preliminary evidence that cognitive-behavioral and coordinated care interventions may increase treatment initiation, while 12-step promotion interventions may promote treatment attendance. More quality studies and greater consistency in treatment utilization measurement are needed.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Psychosocial interventions for people with both severe mental illness and substance misuse

BACKGROUND

Even low levels of substance misuse by people with a severe mental illness can have detrimental effects.

OBJECTIVES

To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care.

SEARCH METHODS

The Information Specialist of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (2 May 2018), which is based on regular searches of major medical and scientific databases.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of risk ratio (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. Where meta-analyses were possible, we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison.

MAIN RESULTS

Our review now includes 41 trials with a total of 4024 participants. We have identified nine comparisons within the included trials and present a summary of our main findings for seven of these below. We were unable to summarise many findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low- or very-low quality due to high or unclear risks of bias because of poor trial methods, or inadequately reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals. 1. Integrated models of care versus standard care (36 months) No clear differences were found between treatment groups for loss to treatment (RR 1.09, 95% CI 0.82 to 1.45; participants = 603; studies = 3; low-quality evidence), death (RR 1.18, 95% CI 0.39 to 3.57; participants = 421; studies = 2; low-quality evidence), alcohol use (RR 1.15, 95% CI 0.84 to 1.56; participants = 143; studies = 1; low-quality evidence), substance use (drug) (RR 0.89, 95% CI 0.63 to 1.25; participants = 85; studies = 1; low-quality evidence), global assessment of functioning (GAF) scores (MD 0.40, 95% CI -2.47 to 3.27; participants = 170; studies = 1; low-quality evidence), or general life satisfaction (QOLI) scores (MD 0.10, 95% CI -0.18 to 0.38; participants = 373; studies = 2; moderate-quality evidence). 2. Non-integrated models of care versus standard care There was no clear difference between treatment groups for numbers lost to treatment at 12 months (RR 1.21, 95% CI 0.73 to 1.99; participants = 134; studies = 3; very low-quality evidence). 3. Cognitive behavioural therapy (CBT) versus standard care There was no clear difference between treatment groups for numbers lost to treatment at three months (RR 1.12, 95% CI 0.44 to 2.86; participants = 152; studies = 2; low-quality evidence), cannabis use at six months (RR 1.30, 95% CI 0.79 to 2.15; participants = 47; studies = 1; very low-quality evidence) or mental state insight (IS) scores by three months (MD 0.52, 95% CI -0.78 to 1.82; participants = 105; studies = 1; low-quality evidence). 4. Contingency management versus standard care We found no clear differences between treatment groups for numbers lost to treatment at three months (RR 1.55, 95% CI 1.13 to 2.11; participants = 255; studies = 2; moderate-quality evidence), number of stimulant positive urine tests at six months (RR 0.83, 95% CI 0.65 to 1.06; participants = 176; studies = 1) or hospitalisations (RR 0.21, 95% CI 0.05 to 0.93; participants = 176; studies = 1); both low-quality evidence. 5. Motivational interviewing (MI) versus standard care We found no clear differences between treatment groups for numbers lost to treatment at six months (RR 1.71, 95% CI 0.63 to 4.64; participants = 62; studies = 1). A clear difference, favouring MI, was observed for abstaining from alcohol (RR 0.36, 95% CI 0.17 to 0.75; participants = 28; studies = 1) but not other substances (MD -0.07, 95% CI -0.56 to 0.42; participants = 89; studies = 1), and no differences were observed in mental state general severity (SCL-90-R) scores (MD -0.19, 95% CI -0.59 to 0.21; participants = 30; studies = 1). All very low-quality evidence. 6. Skills training versus standard care At 12 months, there were no clear differences between treatment groups for numbers lost to treatment (RR 1.42, 95% CI 0.20 to 10.10; participants = 122; studies = 3) or death (RR 0.15, 95% CI 0.02 to 1.42; participants = 121; studies = 1). Very low-quality, and low-quality evidence, respectively. 7. CBT + MI versus standard care At 12 months, there was no clear difference between treatment groups for numbers lost to treatment (RR 0.99, 95% CI 0.62 to 1.59; participants = 327; studies = 1; low-quality evidence), number of deaths (RR 0.60, 95% CI 0.20 to 1.76; participants = 603; studies = 4; low-quality evidence), relapse (RR 0.50, 95% CI 0.24 to 1.04; participants = 36; studies = 1; very low-quality evidence), or GAF scores (MD 1.24, 95% CI -1.86 to 4.34; participants = 445; studies = 4; very low-quality evidence). There was also no clear difference in reduction of drug use by six months (MD 0.19, 95% CI -0.22 to 0.60; participants = 119; studies = 1; low-quality evidence).

AUTHORS' CONCLUSIONS

We included 41 RCTs but were unable to use much data for analyses. There is currently no high-quality evidence to support any one psychosocial treatment over standard care for important outcomes such as remaining in treatment, reduction in substance use or improving mental or global state in people with serious mental illnesses and substance misuse. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high-quality trials are required which address these concerns and improve the evidence in this important area.

Social Support Networks and Symptom Severity Among Patients with Co-occurring Mental Health and Substance Use Disorders

Patients entering an inpatient psychiatry program (N = 406) with co-occurring mental health and substance use disorders reported on their social support networks (source, type) at treatment intake, and completed symptom measures at baseline and 3-, 9-, and 15-month follow-ups (77%). Longitudinal growth models found aspects of participants' support networks were associated with specific symptoms over time. Less family support (i.e., more conflict) was the most consistent predictor of mental health and substance use outcomes and was associated with greater psychiatric, depression, Post Traumatic Stress Disorder (PTSD), and drug use severity. More peer support (via mutual-help involvement) was associated with greater initial improvement in alcohol use severity. Findings suggest that to facilitate the benefits of social support for patients with a dual diagnosis returning to the community, specific components of support should be assessed and considered in the treatment plan, rather than viewing support as a general and undifferentiated factor affecting recovery.

Randomized controlled trial of telephone monitoring with psychiatry inpatients with co-occurring substance use and mental health disorders

Background Psychiatry inpatients frequently have co-occurring substance use and mental health disorders, which are related to poor post-discharge outcomes. Telephone monitoring is effective in specialty substance use disorder treatment settings in increasing continuing care and 12-step program utilization and improving substance use outcomes. This study examined the effectiveness of telephone monitoring among psychiatry inpatients with co-occurring substance use and mental health disorders. Methods This randomized controlled trial (n = 406) compared usual care to usual care plus telephone monitoring (one in-person session during the inpatient stay, followed by weekly telephone contact for three months post-discharge). Follow-ups were conducted at end-of-intervention (three months post-baseline) and nine and 15 months post-baseline (73% followed). Primary outcomes were number of days out of the past 30 of drinking alcohol, using drugs, and experiencing psychological problems. Secondary outcomes were outpatient substance use treatment, and 12-step group, utilization. Results Longitudinal modeling found that patients in both conditions improved over time on each primary outcome. Improvement was comparable between conditions on alcohol and drug use and psychological problems. Receipt of outpatient treatment decreased over the follow-up period and was not related to condition. Likelihood of attending 12-step group meetings did not change over follow-ups, and was not related to condition. Conclusions Improvement over time was evident regardless of condition assignment. Patients maintained attendance at 12-step groups from pre- to post-discharge. Short-term telephone monitoring in addition to usual care for patients with co-occurring substance use and mental health disorders may not be sufficiently intensive to achieve additional improvements on outcomes.

AA attendance and abstinence for dually diagnosed patients: a meta-analytic review

BACKGROUND AND AIMS

There is consensus that best clinical practice for dual diagnosis (DD) is integrated mental health and substance use treatment augmented with Alcoholics Anonymous (AA) attendance. This is the first quantitative review of the direction and magnitude of the association between AA attendance and alcohol abstinence for DD patients.

METHOD

A systematic literature search (1993-2017) identified 22 studies yielding 24 effect sizes that met our inclusion criteria (8075 patients). Inverse-variance weighting of correlation coefficients (r) was used to aggregate sample-level findings and study aims were addressed using random- and mixed-effect models. Sensitivity and publication bias analyses were conducted to assess the likelihood of bias in the overall estimate of AA-related benefit.

RESULTS

AA exposure and abstinence for DD patients were associated significantly and positively [r_w  = 0.249; 95% confidence interval (CI) = 0.203-0.293; tau = 0.097). There was also significant heterogeneity in the distribution of effect sizes and high between-sample variance (I²  = 74.6, P < 0.001). Subgroup analyses indicated that the magnitude of AA-related benefit did not differ between 6- (k = 7) and 12- (k = 12) month follow-up (Q = 0.068, P = 0.794), type of treatment received (in-patient k = 9; intensive out-patient, out-patient, community k = 15; Q = 2.057, P = 0.152), and whether a majority of patients in a sample had (k = 11) or did not have (k = 13) major depression (Q = 0.563, P = 0.453). Sensitivity analyses indicated that the overall meta-analytical estimate of AA benefit was not impacted adversely or substantively by pooling randomized controlled trial (RCT) and observational samples (Q = 0.763, P = 0.382), pooling count, binary and ordinal-based AA (Q = 0.023, P = 0.879) and outcome data (Q = 1.906, P = 0.167) and reversing direction of correlations extracted from studies (Q = 0.006, P = 0.937). No support was found for publication bias.

CONCLUSIONS

Clinical referral of dual diagnosis patients to Alcoholics Anonymous is common and, in many cases, dual diagnosis patients who attend Alcoholics Anonymous will report higher rates of alcohol abstinence relative to dual diagnosis patients who do not attend Alcoholics Anonymous.

Buprenorphine Treatment and 12-step Meeting Attendance: Conflicts, Compatibilities, and Patient Outcomes

This analysis examines patient experiences and outcomes with 12-step recovery group attendance during buprenorphine maintenance treatment (BMT), two approaches with traditionally divergent philosophies regarding opioid medications for treatment of opioid use disorder. Using quantitative (n = 300) and qualitative (n = 20) data collected during a randomized trial of counseling services in buprenorphine treatment, this mixed-methods analysis of African Americans in BMT finds the number of NA meetings attended in the prior 6 months was associated with a higher rate of retention in BMT (p < .001) and heroin/cocaine abstinence at 6 month follow-up (p = .005). However, patients whose counselors required them to attend 12-step meetings did not have better outcomes than patients not required to attend such meetings. Qualitative narratives highlighted patients' strategies for managing dissonant viewpoints on BMT and disclosing BMT status in community 12-step meetings. Twelve-step meeting attendance is associated with better outcomes for BMT patients over the first 6 months of treatment. However, there is no benefit to requiring meeting attendance as a condition of treatment, and clinicians should be aware of potential philosophical conflicts between 12-step and BMT approaches.

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

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