CTN0031%20STAGE-12%20%20Stimulant%20Abuser%20Groups%20to%20Engage%20in12-Step:%20An%20Overview

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CTN0031 STAGE-12 Stimulant Abuser Groups to
Engage in12-StepAn Overview

• Dennis M. Donovan, Ph.D.
• for the
• STAGE-12 Executive Committee
• STAGE-12 Protocol Training Meeting
• Bethesda, MD
• December 3, 2007

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National Executive Committee

• Dennis Donovan, Ph.D., Lead Investigator
• Dennis Daley, Ph.D., Co-Lead Investigator
• Greg Brigham, Ph.D., CTP Representative
• Candace Hodgkins, Ph.D., CTP Representative
• Harold Perl, Ph.D., NIDA Liaison
• Anthony Floyd, Ph.D., National Project Director

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Additional Important People in the STAGE-12
Protocol Development

• DCRI
• Thomas Barfield
• Carl Pieper
• Debbie Drosdick
• Norman Edwards
• Gudaye Tasissa
• Randy Young

• NIDA CCTN
• Paul Wakim
• EMMES
• Carol Wenck
• Amanda Moore
• Kendra Orjada

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General BackgroundWhy a Study about 12-Step?
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Why Consider 12-Step Approaches?

• Why climb a mountain? Because its there.
• Why study 12-Step? Because its a mountain in the
  substance abuse field because its there.

Mt. Rainier
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Why Consider 12-Step Approaches?

• 12-step orientation/philosophy is the predominant
  approach found in U.S. substance abuse treatment
• 12-step groups represent a readily available,
  no-cost recovery resource
• Millions of substance abusers benefit from
  12-step involvement, with increased evidence of
  its effectiveness
• Consistent with community-based treatment program
  and counselor treatment philosophy

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Why Consider 12-Step Approaches?

• Applicable to a broad range of clients in
  different settings and can augment a wide range
  of standard treatments
• A high priority of the CTNs CTP Caucus
• Recent development of efficacious interventions
  to facilitate 12-Step involvement
• Availability of 12-Step Facilitation therapy
  manuals and training materials

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Why Consider 12-Step Approaches?

• Why climb a mountain? Because its there.
• Why study 12-Step? Because its a mountain in the
  substance abuse field because its there.

Mt. Rainier
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Reasons Why 12-Step Facilitation (TSF) is Well
Suited for a CTN Trial

• Can be trained in a relatively short time
• Can augment a wide range of standard treatments
• Can be used by counselors of varying skill levels
• Can be sustained in the CTPs
• Allows an examination of treatment as usual in
  CTPs vis-a-vis 12-Step approaches

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If the effectiveness and durability of TSF is
supported in future research with
cocaine-dependent groups, it would be most
important because of the wide clinical use of
treatments that are consistent with the
theoretical background of the TSF approach
evaluated here, as well as data from Project
MATCH which suggested its effectiveness and
durability with alcohol-dependent populations.
Carroll, et al., 2000
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Why Focus on Facilitating 12-Step Involvement?
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Points Derived from Previous Research on 12-Step
Involvement

• AA and NA participation is associated with
  greater likelihood of abstinence, improved social
  functioning, and greater self-efficacy
• 12-Step self-help groups significantly reduce
  health care utilization and costs
• Combined 12-Step and formal treatment leads to
  better outcomes than found for either alone
• Engaging in other 12-Step group activities seems
  more helpful than attending meetings

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Is Involvement in 12-Step Support (AA, NA, CA)
Related to Improved Outcomes?

• Attendance is not involvement.  
• Longitudinal studies usually, although not
  always, find that 12-Step involvement after
  treatment is associated with higher rates of
  abstinence regardless of the kind of treatment
  received.
• When AA attendance and AA involvement (e.g.,
  reading 12-step literature, getting a sponsor,
  working the steps, or helping set up meetings)
  are both measured, involvement is a stronger
  predictor of outcome.

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Points Derived from Previous Research on 12-Step
Involvement

• Consistent and early attendance/involvement leads
  to better substance use outcomes
• Even small amounts of participation may be
  helpful in increasing abstinence, whereas higher
  doses may be needed to reduce relapse intensity
• Reductions in substance use associated with
  12-Step involvement are not attributable to
  potential third variable influences such as
  motivation, psychopathology, or severity

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Do People Use 12-Step Support During or After
Treatment?

• 75 of alcoholics entering residential treatment
  reported they had attended AA meetings
  previously. However, only 16 indicated that
  they had ever worked any of the 12 Steps.
• Despite strong encouragement to attend, 30 of
  cocaine abusers receiving outpatient treatment
  and 40 of those discharged from inpatient
  treatment reported that they had attended 12-Step
  groups.
• During the follow-up period in the NIDA
  Collaborative Cocaine Treatment Study 33.6 were
  classified as consistently high attenders, 47.9
  as consistently low attenders, and 18.5 as
  decreasing attendance.

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Jones would walk through a blizzard to score
his dope. The question remains what will he do
to get to a meeting?
http//recoveryjonescartoons.com/book_1.htm
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Recommendations from Expert VA/CSAT Consensus
Panel on Self-Help Organizations

• Community-based treatment programs, even those
  that label and represent themselves as 12-Step
  oriented, should evaluate whether their current
  program practices actively support involvement in
  12-Step self-help groups. 
• Programs should examine the methods used by their
  counselors. Typically, when counselors do attempt
  to support 12-Step self-help group involvement,
  they rarely use empirically supported methods.
• When clinicians use empirically validated
  techniques to support mutual help group
  involvement, it is far more likely to occur.

Humphreys, et al., 2004
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Dont We Already Do 12-Step?

• Making the case that treatment programs should
  prioritize self-help group involvement can be
  difficult because many treatment providers
  believe they do this already indeed, that
  every program does.
• In practice, however, what this often means is
  that at some point during treatment a counselor
  gives the patient a list of local self-help
  groups and suggests that the patient attend a
  meeting, which is a minimally effective clinical
  practice.
• We therefore encourage treatment providers to
  use the more intensive methods of promoting
  self-help group involvement empirically
  demonstrated to be effective such efforts will
  maximize the maintenance of treatment gains.

Humphreys Moos, 2007
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It should also be emphasized that TSF is formal
treatment that seeks to foster an enduring
relationship by the patient with self-help it
should not be concluded that merely referring a
patient to a self-help group would be associated
with similar outcomes. Indeed, studies evaluating
referral to self-help compared with formal
12-Step facilitation treatment have suggested
that merely referring substance-dependent
patients to self-help groups is often
insufficient.
(emphasis added)
Carroll, et al., 2000
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Dont We Already Do 12-Step?

• STAGE-12 differs from 12-Step
• Manualized therapy approach based on previous
  research
• Not meetings, but a way to provide a better
  understanding of 12-Step that
• Leads to attending more meetings
• Leads to more involvement in meetings attended
• Leads to engagement in more 12-Step activities
• Actively gets participants into first meetings

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"Stop fighting and surrender, Jones. As your
sponsor, all I ask is that you attend 90
meetings in 90 days."
http//recoveryjonescartoons.com/more_cartoons!.ht
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The STAGE-12 ProtocolAn Overview
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What Is STAGE-12?

• Combined group- and individual-based intervention
  
• Combines elements of Twelve-Step Facilitation
  Therapy and Intensive Referral
• Introduces participants to concepts and
  principles involved in 12-Step groups
• Actively attempts to get participants involved in
  12-Step meetings

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Rationale for Combining Intensive Referral with
Twelve Step Facilitation

• Interventions that are effective in increasing
  attendance may be insufficient to ensure active
  involvement.
• Early attrition from attending meetings may, in
  part, be due to individuals inability to embrace
  or utilize other aspects of the 12-step program
  (Caldwell Cutter,1998)
• Individuals who are attending 12-step groups but
  are having difficulty embracing key aspects of
  the program may need professional assistance that
  focuses more on 12-step practices and tenets and
  less on meeting attendance (Caldwell Cutter,
  1998)

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Twelve-Step Facilitation Therapy http//pubs.niaaa
.nih.gov/publications/match.htm
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Project MATCH Twelve-Step Facilitation

• Developed by Nowinski, Baker Carroll (1992)
  specifically for Project MATCH as an approach
  which
• Manual guided, delivered on an individual basis
• Intended to sharply contrast to CBT and
  Motivational Interviewing
• Approximated frequently used counseling methods
  that invoked 12-Step recovery
• Sought to facilitate meaningful involvement in
  self help groups
• Developed in conjunction with Hazelden Foundation

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What Twelve Step Facilitation Is NOT

• While based on principles of Alcoholics
  Anonymous, TSF is Not 12-Step support group
• TSF is Not equivalent to an AA/NA/CA referral
• TSF is Not equivalent to treatment as usual
• ___________________________________
• TSF is a formal, manualized therapy delivered by
  a counselor

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Focus of Twelve Step Facilitation

• Emphasis on first 3 Steps and fostering
  involvement in AA
• Primary Goals of TSF
• facilitate "acceptance"
• facilitate "surrender"
• facilitate active involvement in 12-Step meetings
  and related activities

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Project MATCH Twelve-Step Facilitation Therapy
PDA
Outpatient Arm of Project MATCH
of Outpatients Attending at Least 1 Meeting
During 12 Month Follow-up
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TSF Therapy for Drug Abuse and Dependence
of Cocaine/Alcohol Dependent Clients with 3 or
More Consecutive Weeks of Abstinence
Days of 12-Step Attendance During 12-week Active
Treatment and 1-Year Follow-up
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12-Step Salmon Recovery Program
                                            
http//www.grist.org/comments/ha/2002/02/04/becker
-salmon/
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The Horns of a Dilemma
Individual TSF
Group TSF
Internal Validity
External Validity
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Most Prior Research on TSF Has Used Individual
Counseling, but the Balance is Beginning to Even
Out
Wells, et al., 1994 T.G. Brown, et al., 2002 S.A.
Brown, et al, 2006
Project MATCH, 1997 Crits-Christoph, et al., 1999
(CCTS) Carroll, et al, 2000
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CTP Survey Results
Which of the following formats would work best
for integrating 12-step facilitation at your CTP
so that you could continue using the
intervention after the study has ended? 1.6
-- Individual therapy 39.1 -- Group
therapy 59.4 -- Group therapy plus some
individual counseling
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CTP Survey Results
If you were to deliver some or all of a 12-step
intervention in a group format, which type of
group would you most likely use 4.6 --
Closed admission group 95.4 -- Open-ended or
rolling admission group
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Systematic Encouragement and Community Access
(SECA) A Buddy System

• Counselor suggests that patient attend AA or
  Al-Anon
• Counselor provides a printed list of meeting
  times and locations
• --------------------------------------------------
  -----------------------------
• In-session telephone call to current member of
  AA, NA or CA, who talks to the patient briefly
  and arranges to attend a meeting with him or her
• Reminder telephone call from the 12-step group
  member the night before the meeting
• 12-step group member drives the patient to or
  arranges to meet the patient at the meeting

Sisson Mallams, 1981
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Intensive Referral to 12-Step Self-Help Groups
and6-Month Substance Use Disorder Outcomes
Abstinent
Magnitude of Change
Abstinent from Alcohol Drugs at Both 6-month
Follow-ups According to 12-Step Involvement
ASI Composite Score
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Why This Combination of Group and Individual
Components?

• Response to requests from treatment community to
  provide a group-based 12-Step facilitative
  approach
• Provides active components to help treatment
  engagement
• Is of a duration that is compatible with IOP
  programs
• Is compatible with CTP reimbursement schedules

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Design of the Intervention

• Group session topics
• Acceptance
• People, Places Things (habits that support
  continued drug use or support recovery)
• Surrender
• Getting Active in 12-Step
• Managing Emotions

These represent core sessions in the TSF
manual
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Design of the Intervention

• Individual sessions
• Introduce 12-step concepts that are discussed
  more thoroughly in group sessions
• Connect the participant with a 12-step group
  member from the community (like a buddy system)
• Have the 12-step member accompany the participant
  to his/her first meeting or act as temporary
  sponsor.
• Review progress in getting engaged and attending
  meetings
• Review overall involvement in STAGE-12 and plan
  for post-intervention involvement in 12-Step
  meetings and activities

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http//recoveryjonescartoons.com/more_cartoons!.ht
m
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Basic Study Questions

• Does STAGE-12 improve substance use outcomes in
  stimulant users compared to treatment-as-usual?
• Does STAGE-12 improve attendance and involvement
  in 12-step groups leading to improved substance
  use outcomes compared to treatment-as-usual

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• Individual presents to CTP for Tx
• Screen for study eligibility
• Informed consent
• Baseline assessment
• Randomized to condition

Treatment as Usual (TAU)
STAGE-12 Integrated into TAU
During Intervention Assessment
End of Intervention Assessment
3-, 6-Month Posttreatment Follow-ups
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Days of substance use
STAGE-12 Intervention
Attendance Involvement in 12-step Groups
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By The Numbers

• 400 stimulant abusing/dependent participants
  recruited
• 9 sites across the country in 2 waves of
  recruitment
• Wave 1 Sites
• Maryhaven from the Ohio Valley Node
• ChangePoint from the Oregon/Hawaii Node
• Recovery Centers of King County from the Pacific
  Northwest Node
• 45 participants per site (20-25 each condition
  -- STAGE-12 or TAU)
• 15 months recruitment at each site
• 3 and 6 month follow-up periods

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Issue STAGE-12 as an Add-On to TAU

• There are tradeoffs with STAGE-12 as either an
  add-on or integrated into treatment as usual
• Integrating it into TAU may displace other
  treatment components, thus modifying TAU
• Adding it to TAU produces differential amounts of
  treatment
• The basic question we are interested in answering
  is Does integrating STAGE-12 into treatment as
  it is typically delivered lead to better outcomes
  than TAU?
• This is also consistent with how CTPs are likely
  to be integrate a 12-step facilitative
  intervention into their program

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Issue Potential Overlap Between TAU and
STAGE-12

• Many CTPs incorporate 12-Step philosophy and
  meetings in their programs
• However, this is often unsystematic and varies
  across CTPs and counselors within CTPs
• Referring substance-dependent patients to
  self-help groups is often insufficient
• STAGE-12 is a systematic, manual-guided, formal
  therapy that seeks to foster an enduring
  relationship by the patient with self-help

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It should be noted that because we evaluated a
closely supervised, manual-guided, individual
version of TSF, our TSF treatment is probably
quite different from that currently used by many
clinicians. It is not clear whether or how much
additional training and supervision would be
required for clinicians in general clinical
settings to deliver TSF as it was implemented
here.
Carroll, et al., 2000
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Three Ancillary Studies Have Attached to
STAGE-12

• Alcohol Assessment
• AUDIT- C items related to alcohol diagnostic
  criteria
• 2. Health Services Research
• Agency organizational influencing intervention
  adoption by CTPs and therapist protocol fidelity
  as a predictor of treatment outcome
• 3. Cognitive Impairment Associated with Stimulant
  Abuse
• Impairment and plasma indicators of oxidative
  stress as predictors of outcome

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"Does anyone have a burning desire to share?"
http//recoveryjonescartoons.com/more_cartoons!.ht
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