Alexandre B. Laudet, Ph.D

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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

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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

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Summary of datasetsused in todays presentation
NIDA funded studies conducted in NYC between 2003
and 2009
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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

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Pathways participants were classified by baseline
abstinence duration according to clinically
meaningful stages
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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

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Measures
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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.

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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

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ACT ONE Effectiveness IT WORKS if you work it
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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
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Sustained abstinence over one year as a function
of baseline level of 12-step affiliation
all p lt.05
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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
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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
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ACT TWO Deconstructing 12-step
involvement(How it works)
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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.

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Past year 12-step attendance _at_ BL and Number of
meetings attended (among attendees)
n.s.
Meeting attendance yes/no
Number of meetings attended
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Any 12-step involvement past year at baseline
and involvement level
n.s.
Any involvement Yes/no
Involvement level Scale range 0 to 9
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Sustained abstinence over three years
Plt.05
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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
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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
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Odds of sustained abstinence over 3 years for
individual 12-step activities _at_ BL controlling
for baseline abstinence duration AMONG MEN
plt .05
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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.

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ACT THREE Examining Attrition It works IF YOU
WORK IT
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Attitudes about 12-step among Outpatient Clients a
a Scale range from 0 to 10
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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
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12-step Attendance status at treatment admission
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Longitudinal 12-step attendance patterns
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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
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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

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Pathways 3-year 12-step affiliation patterns
12-STEP ATTENDANCE AND INVOLVEMENT DECREASE OVER
TIME.
(N 289)
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Reasons for leaving 12-step
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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

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Hmmm.This sounds familiar
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Lessons learnt from Relapse Strategies to deal
with threats to abstinence
C Among those who report a challenge
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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

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ACT FOUR Strategy to foster 12-step affiliation
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Treatment-level predictor of 12-step
participation Onsite meetings
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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
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Abstinence as a function of 12-step meeting
onsite during treatment
All plt.05. Laudet et al. Evaluation Review,
31(6), 613-646, 2007
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All you need to do is call

Call HI, provide a room, a coffee pot - LOTS OF
SUGAR, cookies a plus
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ACT FIVE so what?Integration of Findings
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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

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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.

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THANK YOU for your attention

• Questions?

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