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Alexandre B. Laudet, Ph.D

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Title: Alexandre B. Laudet, Ph.D


1
12-step participation among polysubstance
usersLongitudinal patterns, effectiveness, and
(some) lessons learned
  • Alexandre B. Laudet, Ph.D
  • Presented at the University of Michigan, Sept.
    24-25, 2009

2
Background
  • The bulk of 12-step research has focused on
    alcohol dependent persons, most of whom were
    recruited in treatment
  • Millions of 12-step members worldwide continue
    attending meetings for drugs and/or alcohol
    problems, after or in lieu of treatment, some for
    multiple years after achieving abstinence
  • The effectiveness of this practice has rarely
    been empirically examined

3
Summary of datasetsused in todays presentation
NIDA funded studies conducted in NYC between 2003
and 2009
4
Pathways The community-based sample
  • Study funded to elucidate patterns and
    psychosocial predictors of stable abstinence from
    drugs and alcohol use
  • Media recruited sample (N 354) re-interviewed
    yearly 3 times one-, two- and three year
    follow-up (83 retention of surviving BL cohort
    of 342)
  • Primarily members of inner-city ethnic,
    underserved minorities
  • Long severe history of (primarily) crack and/or
    heroin use
  • Almost all were polysubstance users
  • Self-reported abstinence at baseline from one
    month to 10 years
  • 30 HepC and 22 HIV

5
Pathways participants were classified by baseline
abstinence duration according to clinically
meaningful stages
6
Twelve-step as aftercare The outpatient
treatment sample
  • Study funded to identify predictors, patterns and
    outcomes of 12 step participation after
    outpatient
  • Recruited 250 consecutive admissions at two
    publicly funded outpatient programs
  • Follow-up interviews Treatment end, 3-, 6- and
    12-months post treatment end
  • Full dataset on 219 participants ( 87.6
    retention) one year post discharge
  • Primarily members of inner-city ethnic,
    underserved minorities with long severe history
    of (primarily) crack and/or heroin use
  • 85 had had treatment before average of 5.8
    previous treatment episodes

7
Measures
8
Measures of 12-step affiliation
  • Meeting Attendance Number of AA NA meetings
    attended during the target period (looked at
    Cocaine Anonymous, few if any, attend)
  • 12-step Involvement Sum score of participation
    in nine 12-step suggested activities
  • Having a sponsor
  • Sponsoring someone
  • Reading recovery literature
  • Having a home group
  • Considering oneself a 12-step member
  • Doing service
  • Working the steps
  • Contacting 12-step members outside of meetings
    and
  • Socializing with other members outside of
    meetings.

9
Measures of substance use outcomes
  • Most studies examine the use of a single
    substance - e.g., alcohol or cocaine, over a
    short period (e.g., prior 30 to 90 days)
  • Expert panels and persons in recovery agree that
    recovery requires
  • Total abstinence from drugs and alcohol
  • Maintained continuously
  • We operationalize abstinence as No self-reported
    use of drugs or alcohol during the target period,
    obtained as follows
  • Ever use 13 ASI substances?
  • For each ever used once of more Last date of
    use?
  • Compute abstinence duration for each substance
  • Participants abstinence period Shortest period
    of any substance
  • Biological corroboration with hair or saliva
    sample
  • For analyses requiring dichotomous variable
  • IF shortest abstinent period gt target study
    period THEN participants abstinence status YES
  • For multiple periods continuous abstinence

10
ACT ONE Effectiveness IT WORKS if you work it
11
Twelve-step participation fosters stable
abstinence from polydrug use
Rarely have we seen a person fail who has
thoroughly followed our path Big Book, Chap. 5
How it works
12
Sustained abstinence over one year as a function
of baseline level of 12-step affiliation
all p lt.05
13
Sustained abstinence over three years at F3 as a
function of continuous 12-step attendance
all p lt.01
Controlling for BL abstinence duration and
lifetime dependence severity
14
Role of continuous 12-step attendance and
involvement over 3 years on odds of sustained
abstinence
Controlling for BL abstinence duration and
lifetime dependence severity - all p lt.05
15
ACT TWO Deconstructing 12-step
involvement(How it works)
16
Deconstructing 12-step involvement
  • Many substance users choose not to attend 12-step
    meetings or they drop out after a short period of
    attendance.
  • Involvement in 12-step activities (e.g., reading
    recovery literature, having a sponsor) enhances
    the likelihood of stable abstinence independently
    of meeting attendance
  • Growing knowledge base about mechanisms of action
    of meeting attendance
  • There is a need to specify the elements of
    12-step involvement that underlie its benefits
    and may be helpful independently of meeting
    attendance or even outside of the 12-step
    context.
  • We examine
  • The role of overall 12-step involvement level at
    baseline in predicting continuous abstinence
    sustained over three years independently of
    meeting attendance and
  • Gender differences in these processes.

17
Past year 12-step attendance _at_ BL and Number of
meetings attended (among attendees)
n.s.
Meeting attendance yes/no
Number of meetings attended
18
Any 12-step involvement past year at baseline
and involvement level
n.s.
Any involvement Yes/no
Involvement level Scale range 0 to 9
19
Sustained abstinence over three years
Plt.05
20
Odds of sustained abstinence over 3 years as a
function of baseline 12-step involvement
controlling for baseline abstinence duration and
12-step meeting attendance
plt.05
21
Odds of sustained abstinence over 3 years for
individual 12-step activities _at_ BL controlling
for baseline abstinence duration AMONG WOMEN
plt .05 plt .01
22
Odds of sustained abstinence over 3 years for
individual 12-step activities _at_ BL controlling
for baseline abstinence duration AMONG MEN
plt .05
23
Deconstructing 12-step involvementImplications
  • AT BASELINE, no gender differences in substance
    use history, prior exposure to treatment (not
    shown), 12-step affiliation.
  • Yet women significantly more likely than men to
    sustain abstinence over three years.
  • BL 12-step involvement level significantly
    predicted continuously sustained abstinence over
    three years independently of meeting attendance
    among women but not among men.
  • Some of the individual 12-step activities
    associated with sustained abstinence among women
    are specific to the 12-step context (Identifying
    as a 12-step member, having a sponsor and a home
    group).
  • Others may be translated outside of 12-step
    recovery for persons who elect not to affiliate
    with 12-step
  • Doing service volunteering
  • Spending time with other persons in recovery
    regardless of 12-step affiliation
  • More research is needed to determine the benefits
    of such activities outside of the 12-step context
    in sustaining abstinence and to elucidate gender
    differences.

24
ACT THREE Examining Attrition It works IF YOU
WORK IT
25
Attitudes about 12-step among Outpatient Clients a
a Scale range from 0 to 10
26
Reasons for Attending NA and AA
  • NARCOTICS ALCOHOLICS
  • ANONYMOUS ANONYMOUS
  • (N150)
    (N88)
  • Promotes recovery/sobriety 59 41
  • Support/acceptance/fellowship 33 58
  • None (did not get anything out of it) 18 10
  • Mandated/pressured 11 6
  • To make friends, to check it out 4 4
  • Step work, spirituality 3 8

Among ever attenders total gt100 b/c up to 3
answers coded
27
12-step Attendance status at treatment admission
28
Longitudinal 12-step attendance patterns
29
12-step attrition Ever dropped out?
Since you first started attending 12-step, have
you ever stopped attending for a month or
longer? (yes)
Other than being in a closed institution Among
current attenders
30
12-step Participation Patterns mirror treatment
career
  • How many different times did you stop attending
    for a month or longer since you began attending
    meetings?
  • Narcotics Anonymous-mean (SD) 6.1 (13.2)
  • Alcoholics Anonymous 6.4 (12.1)
  • How long was the longest interruption in
    attendance? (in months)
  • Narcotics Anonymous- mean (SD) 29.8 (27.7)
  • Alcoholics Anonymous 29.9 (30.8)
  • THE 12-STEP CAREER, LIKE the TREATMENT CAREER,
    CONSISTS OF MULTIPLE INTERRUPTED EPISODES OF
    PARTICIPATION

31
Pathways 3-year 12-step affiliation patterns
12-STEP ATTENDANCE AND INVOLVEMENT DECREASE OVER
TIME.
(N 289)
32
Reasons for leaving 12-step
33
Reasons for 12-step attrition
  • Why did you stop attending? (longest interrupted
    period)
  • NARCOTICS ALCOHOLICS
  • ANONYMOUS ANONYMOUS
  • (N120) (N72)
  • Using/not ready to stop 27 33
  • Didnt like it/tired of it 26 19
  • Didnt need it/I can recover on my own 25 0
  • Limited to drug or alcohol/no identification 0 1
    5
  • Not helpful 13 1
  • Went to alternative fellowship 6 8
  • Time/location fellowship 8 15
  • Not comfortable sharing 5 0
  • Not required 0 4
  • No reason 3 13
  • Among those reporting disengagement, total
    gt100 b/c up to 3 answers coded

34
Hmmm.This sounds familiar
35
Lessons learnt from Relapse Strategies to deal
with threats to abstinence
C Among those who report a challenge
36
Observation and clinical hint
  • Lessons learnt from relapse about what it takes
    to recover
  • Must want to recover/stay focused
  • Cannot do it alone
  • Reasons for not going to 12-step
  • Not ready to recover (motivation)
  • I can do it on my own (dont need support)
  • Moral of the story
  • MOTIVATION ENHANCEMENT and
  • ACCEPTING/SEEKING SUPPORT

37
ACT FOUR Strategy to foster 12-step affiliation
38
Treatment-level predictor of 12-step
participation Onsite meetings
39
Number of 12-step meetings past month as a
function of 12-step meeting onsite during
treatment
All plt.05 except where noted trend p .069.
Laudet et al. Evaluation Review, 31(6), 613-646,
2007
40
Abstinence as a function of 12-step meeting
onsite during treatment
All plt.05. Laudet et al. Evaluation Review,
31(6), 613-646, 2007
41
All you need to do is call

Call HI, provide a room, a coffee pot - LOTS OF
SUGAR, cookies a plus
42
ACT FIVE so what?Integration of Findings
43
Integration of Findings It works
  • Twelve-step affiliation significantly enhances
    the odds of sustaining abstinence for multiple
    years among polysubstance dependent persons
  • This extends in scope and in time the empirical
    knowledge base on the effectiveness of 12-step
    affiliation for addressing substance use
    disorders
  • Polysubstance use (vs. alcohol and/or single
    substance)
  • To community-based polysubstance users (vs.
    treatment clients)
  • To abstinence maintenance (vs. initiation)
  • 12-step involvement
  • Especially beneficial for persons with several
    years of abstinence
  • Appears particularly important for women
  • Several components of 12-step involvement may be
    transferable outside the 12-step context

44
Integration of Findings IF you work it
  • Twelve step meeting attendance
  • Declines over time, possibly mitigating its
    usefulness
  • Longitudinal patterns mirror addiction and
    treatment careers (multiple interrupted
    episodes)
  • A substantial minority of substance users choose
    not to participate in 12-step
  • Though reasons for not attending vary, a number
    of factors cited echo perceived reasons for
    returning to active substance use and center on
  • MOTIVATION Wanting to use/not motivated to stop
  • Low problem recognition
  • Low recognition of need to seek/accept help
  • Treatment programs can easily enhance the
    likelihood of post treatment 12-step
    participation and abstinence by holding a meeting
    onsite.

45
THANK YOU for your attention
  • Questions?

46
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