Do treatment process factors mediate the relationship between type A-type B and outcome in 12-Step oriented substance abuse treatment?

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

Purpose

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

Design/methodology/approach

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

Findings

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

Practical implications

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

Originality/value

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

Using Factor Mixture Models to Evaluate the Type A/B Classification of Alcohol Use Disorders in a Heterogeneous Treatment Sample

BACKGROUND

The type A/B classification model for alcohol use disorders (AUDs) has received considerable empirical support. However, few studies examine the underlying latent structure of this subtyping model, which has been challenged as a dichotomization of a single drinking severity dimension. Type B, relative to type A, alcoholics represent those with early age of onset, greater familial risk, and worse outcomes from alcohol use.

METHODS

We examined the latent structure of the type A/B model using categorical, dimensional, and factor mixture models in a mixed-gender community treatment-seeking sample of adults with an AUD.

RESULTS

Factor analytic models identified 2 factors (drinking severity/externalizing psychopathology and internalizing psychopathology) underlying the type A/B indicators. A factor mixture model with 2 dimensions and 3 classes emerged as the best overall fitting model. The classes reflected a type A class and 2 type B classes (B1 and B2) that differed on the respective level of drinking severity/externalizing pathology and internalizing pathology. Type B1 had a greater prevalence of women and more internalizing pathology and B2 had a greater prevalence of men and more drinking severity/externalizing pathology. The 2-factor, 3-class model also exhibited predictive validity by explaining significant variance in 12-month drinking and drug use outcomes.

CONCLUSIONS

The model identified in this study may provide a basis for examining different sources of heterogeneity in the course and outcome of AUDs.

Pathways to Vulnerability for Alcohol Problem Severity in a Treatment-Seeking Sample

OBJECTIVES

The present investigation examined the role of gender, family history of alcohol and drug use disorders, temperament, childhood behavior problems, and adult psychopathology, on adult alcohol use disorder (AUD) severity.

METHODS

Structural equation modeling was used to examine multiple etiological pathways to adult alcohol use disorder (AUD) severity. Participants included 335 treatment-seeking males and females with current or lifetime DSM-III-R alcohol dependence (96%) or abuse (4%) enrolled in one of five treatment outcome studies. Extensive assessment at treatment entry used a mixture of retrospective and current self-report.

RESULTS

Results identified two significant paths associated with a latent factor of adult alcohol use disorder severity at entry to treatment. In Path 1, male gender and family history of drug use disorder predicted greater childhood behavior problems, which predicted antisocial personality disorder (ASPD), borderline personality disorder (BPD), and anxiety disorders (ADs), with anxiety disorders leading directly to alcohol use disorder severity. In Path 2, family history of alcohol use disorder predicted difficult temperament in childhood, which predicted borderline personality disorder, major depressive disorder (MDD) and anxiety disorders; both major depressive disorder and anxiety disorders in turn predicted alcohol use disorder severity at treatment entry.

CONCLUSIONS

The present findings build on the literature on heterogeneity in developmental risk processes leading to the expression of adult alcohol use disorder symptomology among patients presenting for alcohol use disorder treatment.

Psychometric Evaluation of the Substance Use Risk Profile Scale (SURPS) in an Inpatient Sample of Substance Users Using Cue-Reactivity Methodology

The current project sought to examine the psychometric properties of a personality based measure (Substance Use Risk Profile Scale; SURPS: introversion-hopelessness, anxiety sensitivity, impulsivity, and sensation seeking) designed to differentially predict substance use preferences and patterns by matching primary personality-based motives for use to the specific effects of various psychoactive substances. Specifically, we sought to validate the SURPS in a clinical sample of substance users using cue reactivity methodology to assess current inclinations to consume a wide range of psychoactive substances. Using confirmatory factor analysis and correlational analyses, the SURPS demonstrated good psychometric properties and construct validity. Further, impulsivity and sensation-seeking were associated with use of multiple substances but could be differentiated by motives for use and susceptibility to the reinforcing effects of stimulants (i.e., impulsivity) and alcohol (i.e. sensation-seeking). In contrast, introversion-hopelessness and anxiety sensitivity demonstrated a pattern of use more focused on reducing negative affect, but were not differentiated based on specific patterns of use. Taken together, results suggests that among those receiving inpatient treatment for substance use disorders, the SURPS is a valid instrument for measuring four distinct personality dimensions that may be sensitive to motivational susceptibilities to specific patterns of alcohol and drug use.

Applicability of Type A/B alcohol dependence in the general population

BACKGROUND

This study examined the concurrent and predictive validity of Type A/B alcohol dependence in the general population-a typology developed in clinical populations to gauge severity of dependence.

METHODS

Data were drawn from Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). The sample included 1,172 alcohol-dependent drinkers at baseline who were reinterviewed three years later. Latent class analysis was used to derive Type A/B classification using variables replicating the original Type A/B typology. Predictive validity of the Type A/B classification was assessed by multivariable linear and logistic regressions.

RESULTS

A two-class solution consistent with Babor's original Type A/B typology adequately fit the data. Type B alcoholics in the general population, compared to Type As, had higher alcohol severity and more co-occurring drug, mental, and physical health problems. In the absence of treatment services utilization, Type B drinkers had two times the odds of being alcohol dependent three years later. Among those who utilized alcohol treatment services, Type B membership was predictive of heavy drinking and drug dependence, but not alcohol dependence, three years later.

CONCLUSIONS

Findings suggest that Type A/B classification is both generalizable to, and valid within, the US general population of alcohol dependent drinkers. Results highlight the value of treatment for mitigating the persistence of dependence among Type B alcoholics in the general population. Screening for markers of vulnerability to Type B dependence could be of clinical value for health care providers to determine appropriate intervention.

The general environment fit scale: a factor analysis and test of convergent construct validity

Person-environment fit (P-E fit) was initially espoused as an important construct in the field of community psychology; however, most of the theoretical and empirical development of the construct has been conducted by the industrial/organizational (I/O) psychologists and business management fields. In the current study, the GEFS-a P-E fit measure that was developed from organizational perspectives on fit-was administered to 246 attendees of an annual convention for residents and alumni of Oxford House, a network of over 1,400 mutual-help addiction recovery homes. The authors conducted confirmatory factor and convergent construct validity analyses with the GEFS. The results suggested that the theoretical factor structure of the measure adequately fit the data and provided limited support for the measure's validity. Sufficient supply of resident needs by the Oxford House and similarity between residents and their housemates predicted satisfaction with the recovery home, but only perceived similarity to housemates predicted how long residents intended to stay in the Oxford Houses.

Structural, concurrent, and predictive validity of the Substance Use Risk Profile Scale in early adolescence

A brief personality risk profile (23 items), the Substance Use Risk Profile Scale was tested for concurrent and predictive validity for substance use in 1139 adolescents (grades 8-10) from a mid-sized city in western Canada. The SURPS was administered in two waves of a longitudinal study separated by 12 months (2003-04). As expected, four subscales were supported by confirmatory factor and metric invariance analysis. In regression analysis, three subscales, hopelessness, impulsivity, and sensation seeking, were positively related to current and future use; while one, anxiety sensitivity, was negatively related. Findings suggest clinical utility for screening adolescents at risk for substance use.

The Substance Use Risk Profile Scale: a scale measuring traits linked to reinforcement-specific substance use profiles

The Substance Use Risk Profile Scale (SURPS) is based on a model of personality risk for substance abuse in which four personality dimensions (hopelessness, anxiety sensitivity, impulsivity, and sensation seeking) are hypothesized to differentially relate to specific patterns of substance use. The current series of studies is a preliminary exploration of the psychometric properties of the SURPS in two populations (undergraduate and high school students). In study 1, an analysis of the internal structure of two versions of the SURPS shows that the abbreviated version best reflects the 4-factor structure. Concurrent, discriminant, and incremental validity of the SURPS is supported by convergent/divergent relationships between the SURPS subscales and other theoretically relevant personality and drug use criterion measures. In Study 2, the factorial structure of the SURPS is confirmed and evidence is provided for its test-retest reliability and validity with respect to measuring personality vulnerability to reinforcement-specific substance use patterns. In Study 3, the SURPS was administered in a more youthful population to test its sensitivity in identifying younger problematic drinkers. The results from the current series of studies demonstrate support for the reliability and construct validity of the SURPS, and suggest that four personality dimensions may be linked to substance-related behavior through different reinforcement processes. This brief assessment tool may have important implications for clinicians and future research.

Effectiveness of Making Alcoholics Anonymous Easier: a group format 12-step facilitation approach

Most treatment programs recommend clients attend 12-step groups, but many drop out posttreatment. The effectiveness of Making Alcoholics Anonymous [AA] Easier (MAAEZ ), a manual-guided 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. MAAEZ represents an evidence-based intervention that is easily implemented in existing treatment programs.

Active ingredients of substance use-focused self-help groups

AIMS AND METHODS

This paper provides an overview of some of the probable active ingredients of self-help groups in light of four related theories that identify common social processes that appear to underlie effective psychosocial treatments for and continuing remission from these disorders.

RESULTS

Social control theory specifies active ingredients such as bonding, goal direction and structure; social learning theory specifies the importance of norms and role models, behavioral economics and behavioral choice theory emphasizes involvement in rewarding activities other than substance use, and stress and coping theory highlights building self-efficacy and effective coping skills. A review of existing studies suggests that the emphasis on these active ingredients probably underlies some aspects of the effectiveness of self-help groups.

CONCLUSIONS

Several issues that need to be addressed to enhance understanding of the active ingredients of action of self-help groups are discussed, including consideration of indices of Alcoholics Anonymous (AA) affiliation as active ingredients, identification of personal characteristics that may moderate the influence of active ingredients on substance use outcomes, examination of whether active ingredients of self-help groups, can amplify or compensate for treatment, identification of potential detrimental effects of involvement in self-help groups and focusing on the link between active ingredients of self-help groups and other aspects of the overall recovery milieu, such as the family and social networks.

Is alcoholism typology a predictor of both Alcoholics Anonymous affiliation and disaffiliation after treatment?

Twelve Steps (TS) has demonstrated effectiveness; induction into Alcoholics Anonymous (AA) is a primary objective of TS and is a pivotal mechanism explaining its effectiveness. However, evidence suggests that, after treatment, dropout from AA is high. This study investigated whether alcohol problem severity predicted both AA affiliation and disaffiliation among clients receiving TS. This study of a Project MATCH sample included 453 alcohol-dependent clients randomly assigned to TS who reported AA attendance during treatment. Greater alcohol problem severity predicted AA attendance; opposite to prediction, less alcohol-impaired clients were more than twice as likely to discontinue AA attendance after treatment. When sustained AA attendance is desired, the evaluation of client pretreatment alcohol involvement may be useful for identifying potential AA dropout after TS treatment. Findings also indicate that, among treatment-seeking problem drinkers, AA dropout and disaffiliation are distinct, albeit correlated, constructs that require future investigation.

The Type A-Type B classification in a community sample of problem drinkers: structural and predictive validity

OBJECTIVE

The Type A-Type B multidimensional classification model has been useful for identifying a subgroup of alcohol dependent drinkers with more severe psychosocial problems and a poor prognosis. Evidence suggests its dimensions may be useful for identifying problem drinkers in the general population at risk for developing alcohol dependence. To date, the model has not yet been investigated for this purpose. The present study investigated the Type A/Type B distinction in a community sample of problem drinkers as well as its predictive validity among problem drinkers with no history of alcohol dependence.

METHOD

Households from a geographically delimited area in the United States were designated via random digit dialing and randomly designated members were screened for eligibility. A total of 876 participants met eligibility criteria and completed a structured interview (AUDADIS) on alcohol and other health related behaviors at baseline and at 1-year follow-up. A k-means cluster analysis was performed to identify subgroups of problem drinkers.

RESULTS

A two-cluster solution adequately fit the data and identified two main subgroups of problem drinkers consistent with a Type A-Type B distinction. The group differences held among those with and without a history of alcohol dependence and the subset of Type B drinkers with no history of alcohol dependence were approximately five times (beta = 1.56, p< or =0.01) more likely to have an initial onset of dependence than Type A drinkers at 1-year follow-up. In contrast, a DSM-IV alcohol abuse diagnosis at baseline did not predict 1-year onset of dependence.

CONCLUSIONS

The Type A-Type B model is useful for identifying untreated problem drinkers at risk for developing alcohol dependence. This model may facilitate the development of more targeted prevention efforts.

Typologies of drug dependence: comparative validity of a multivariate and four univariate models

Data from a longitudinal cohort study were used to directly compare the concurrent and predictive validity of four univariate typologic approaches with a multivariate approach in subtyping drug dependence. The four univariate typologies were based upon: (a) age-of-onset of drug abuse/dependence, (b) presence of drug abuse in first-degree relatives, (c) presence of antisocial personality disorder, and (d) sex. The multivariate typologic approach was based on indices of vulnerability, chronicity, consequences, and psychopathology, yielding the Type A/B dichotomy first demonstrated in alcohol dependence. Subtypes generated from the univariate typologies were then each compared with the multivariate typology on measures of concurrent and predictive validity, and the strength of association was compared statistically. There was evidence of significantly greater concurrent validity of the Type A/B typology compared with the univariate typologies across all the domains of validation (risk, substance use, psychopathology, personality, and overall functioning). The multivariate typology also fared better than the univariate ones in all three domains on which predictive validity was evaluated: substance use, psychopathology, and overall functioning, as well as the degree of change in several composite scores (drug, medical, legal, and psychiatric) and the global psychiatric symptom index. This direct method of comparison seemed to demonstrate the superior validity of the multivariate cluster-analytic approach over the univariate approaches to classifying subjects with drug dependence.

Examining mechanisms of action in 12-Step community outpatient treatment

Twelve-step theory hypothesizes that changes in specific cognitions and behaviors, including adoption of disease model beliefs and involvement in self-help programs, lead to symptom reduction. We examined the role of self-help affiliation in treatment outcome using causal chain analysis. Baseline, end-treatment and follow-up self-help affiliation and substance use were assessed in 252 drug and alcohol abusers attending a community program. Participants were randomly assigned to one of three cognitive-behavioral or 12-Step oriented individual counseling conditions. Participants also were assigned, based on problem severity, to one of three treatment settings (partial hospitalization; intensive outpatient; standard outpatient) that varied according to intensity of additional 12-Step programming. Repeated-measures ANOVA indicated that self-help affiliation increased overall during treatment, particularly in the 12-Step counseling condition (versus cognitive-behavioral), and the partial hospitalization setting (versus standard outpatient). Multiple regression indicated that self-help affiliation was negatively associated with substance use 6 months post-treatment, and that this was not moderated by condition. Self-help affiliation predicted outcome most strongly in the partial hospitalization setting and not at all in outpatient; however, this effect was accounted for by participants' initial problem severity: high-severity patients had poorer outcomes if they failed to increase self-help affiliation, relative to those who increased affiliation and to low-severity patients regardless of affiliation. Results indicate that, in this community-based program, self-help affiliation increased as a function of exposure to 12-Step oriented treatment programming, and significantly predicted better outcome among patients with high levels of problem severity. Implications for future treatment process and dissemination research are discussed.

Effective technology transfer in alcoholism treatment

Alcoholism treatment services in the United States continue to be characterized by a lack of evidence-based care. Problems establishing effective research-practice knowledge transfer stem, in part, from the strong allegiance of scientists and practitioners to contrasting treatment models. Four underlying assumptions of the Minnesota model that continue to guide the delivery of alcohol services in the United States are identified and related research is reviewed. Findings indicate little support for these assumptions. However, support for superiority of alternative science-based treatments to replace current practices varies. To facilitate effective technology transfer, research practitioner collaboration must be promoted. Research paradigms are needed that possess high salience to practitioners while preserving scientific rigor. Two examples of studies involving research-practitioner collaboration are described.