12-Step Familiarity vs 12-Step Facilitation

A pair of studies were published last month to little fanfare and which seem to be contradictory in nature. Both papers involve 12-step programs and focus on the role of the counselor in delivering Twelve-Step Facilitation (TSF), a SAMHSA-recognized evidence-based practice. Published in the American Journal of Drug and Alcohol Abuse, the studies come to the following conclusions: Therapist familiarity and personal experience with twelve-step programs (TSPs) improves their credibility among clients and, in turn, therapeutic alliance; yet therapists who viewed TSPs favorably and who described themselves as being in recovery tended to do a poorer job at maintaining fidelity and adherence to TSF in a large, multi-site trial.

In the first paper, researchers at the State University of New York administered surveys to clients and counselors at a host of treatment programs in and around Albany. Clients (n=180) rated counselors on their perceived familiarity with  TSPs, the amount of time in-session devoted to discussion of TSPs, and the credibility of each counselor, as rated in a 12-point questionnaire. In addition, counselors (n=30) answered a demographic questionnaire, reporting such information as education level, recovery status, and months of experience in the field. As hypothesized, counselors who were perceived to be in recovery and more personally-familiar with TSPs received higher ratings of credibility from their clients, presumably resulting in better therapeutic alliances and, therefore, better outcomes.

In the second paper, researchers in Oregon and California sought to determine the characteristics associated with fidelity and TSF adherence among therapists participating in a large trial of the EBP. Notably, the authors found that 1) "Therapists reporting more positive attitudes toward 12-step groups had lower adherence ratings;" 2) "Being in recovery was associated with lower fidelity in univariate tests, but higher adherence in multivariate analysis;" and 3), "Fidelity was higher for therapists reporting self-efficacy in basic counseling skills" (as well as for therapists with a graduate degree) "and lower for self-efficacy in addiction-specific counseling skills." 

The "juxtaposition" of the two outcomes, as Yale's Steve Martino puts it, leads the reader to believe that the ideal therapist in this setting can't possibly exist, or ar the very least is exceedingly rare. Someone who is very familiar with 12-step principles is likely to report a positive attitude toward them, and counselors in recovery are likely to rate themselves as possessing strong addiction-specific counseling skills. So, what is the moral to the story, if one exists? Where do we focus workforce development energy with mixed messages like these? It would be interesting to hear from readers who fall on either side (or both sides) of this issue...

Sunday Alcohol Blue Laws: Keeping consumption in-check?

In a brand new paper by SUNY economist Bans Yoruk, the author analyzes alcohol consumption rates in five states which recently repealed laws banning the sale of alcohol on Sundays. The findings, published online this month in the journal Addiction, show that in three of the five states, per capita alcohol consumption rose significantly in the years following the repeals. Beer seems to be the type of alcohol responsible for most of the increase across the states, with wine and spirits seeing small, if any, changes in demand.

The five states studied were Delaware, which repealed its law against Sunday alcohol sales in 2003, as did Massachusetts and Pennsylvania; Rhode Island, which repealed in 2004; and New Mexico, where the law was changed in 1995. The three states whose per capita consumption increased were Delaware (from 4% pre-repeal to 4.7% post-repeal), Pennsylvania (4% to 4.6%), and New Mexico (6.5% to 7.1%). The increase in Rhode Island was “small and statistically insignificant,” and there was no change in Massachusetts. (Interestingly, the demand for beer seemed to drive the up-tick in sales – all three states where the overall demand rose saw beer consumption increase by about a full percentage point.) The five states were then compared to control states, like our beautiful Minnesota, where alcohol Blue Laws remain in effect. 

Here's the graph from the paper:

Professor Yoruk's analysis falls on the heels of another study which tracked the effects of, among other variables, perceived alcohol availability and bar density on adolescent alcohol consumption. Paschall, et al. found such environmental factors contributed significantly to higher rates of past-year alcohol use. Could it be that an archaic and puritanical relic could actually be saving some lives? Will be interesting to see what readers think about the issue…

Sources:

        Paschall, M. J., Lipperman‐Kreda, S., & Grube, J. W. (2013). Effects of the Local Alcohol Environment on Adolescents’ Drinking Behaviors and Beliefs.Addiction.

        Yörük, B. K. (2013). Legalization of Sunday alcohol sales and alcohol consumption in the United States. Addiction.

Advice for Consumers of Addiction Services

In the November issue of the prestigious journal Health Affairs, Anne Fletcher's book Inside Rehab got a very favorable review. Yours truly was highlighted with this paragraph from the review:

"Certainly the most useful part of the book is the advice provided by Mark Willenbring, former director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism. He recommends that those seeking treatment should see themselves as customers and seek the best treatment that will work for them. They should get a comprehensive evaluation from someone not financially invested in a specific treatment program, demand nothing less than master’s degree–prepared therapists, and make sure the program treats any co-occurring issues. They should also not go through the same treatment protocols over and over again when it is obvious that they aren't working."

Thanks to Anne of course, and also to the reviewer, Rick Mathis (Richard_Mathis@bcbst.com), a a health
researcher at the BlueCross BlueShield of Tennessee Health Institute.

MW

New Findings in Medication-Assisted Treatment

Some interesting new studies are showing promising results for patients all over the world:

Turns out, Quality of Life improvements aren't just for the wealthy:
Quality of Life (QoL) scores significantly improved in ALL four domains (psychological, physical, social and environmental) of the WHO QoL scale in patients in low and middle income countries, according to the authors of a systematic review of 13 studies involving over 1800 participants. The findings, published online last week in the Journal of Drug and Alcohol Dependence, show that despite the apparent lack of resources in these countries, opiate replacement therapy with methadone or buprenorphine can be an effective treatment tool - with scores increasing along with the length of time at followup - and offering outcomes comparable to those seen in high income countries.
You can read the abstract of the study by Feelemeyer, et al., here: http://www.sciencedirect.com/science/article/pii/S0376871613004225

The methadone of methamphetamine?:
In encouraging news for stimulant users, a small study has shown methylphenidate (Ritalin) to both improve symptoms and reduce use episodes, in a cohort of criminal justice-involved stimulant users with co-occurring ADHD. Similar findings have been published supporting mixed-amphetamine salts (Adderall) plus topiramate (Topamax) for the treatment of cocaine dependence, and more recently topiramate by itself. The authors of the small study note the high prevalence of ADHD among stimulant users in the criminal justice population and in their research used dosages that were high enough to be therapeutically effective for patients with a history of substance use disorders (a flaw, they argue, in previous studies of this kind). Could it be that we are getting closer to an accepted agonist maintenance treatment for stimulant use disorders? Read the results of the Swedish study by Konstenius, et al., published online this month in the journal Addiction:
http://onlinelibrary.wiley.com/doi/10.1111/add.12369/abstract

Groups could improve access to AUD medications:
And finally, in a new study in the Journal of Substance Abuse Treatment, researchers have shown that group pharmacotherapy is an effective intervention for patients on medication-assisted treatment of alcohol use disorders. The authors provide a brief description of this novel approach and their experiences implementing the program. They note that, for many clinicians, providing ongoing monitoring of these effective medications can create a barrier to implementation. What the team found however, was that a "medication group" was not only feasible, but it actually increased their patients' access to meds like disulfiram (Antabuse), naltrexone and acamprosate (Campral). Read the abstract from the report by Dr Shannon Robinson and a team at San Diego's VA Health Care System here: http://www.sciencedirect.com/science/article/pii/S0740547213001347

Overcoming Addictions, a web-based application, & SMART Recovery: Outcomes of a randomized clinical trial

This week's entry comes from Dr Reid K Hester, PhD. He is Director of the Research Division at Behavior Therapy Associates, LLC, where they have been conducting some exciting new research using a web-based application, Overcoming Addictions. Thank you, Dr Hester, for the guest post:

Overcoming Addictions, a web-based application, & SMART Recovery: Outcomes of a 

randomized clinical trial

My research staff and I recently published the early outcomes of a new web app, Overcoming Addictions in the Journal of Medical Internet Research (http://www.jmir.org/2013/7/e134). Overcoming Addictions (OA, www.overcomingaddictions.net) is an abstinence-oriented, cognitive behavioral program based on the protocol of SMART Recovery. SMART Recovery (www.smartrecovery.org) is an organization that has adapted empirically supported treatment strategies for use in a mutual help framework with in-person meetings, online meetings, a forum and other resources.

A firm believer of “In God we trust, everyone else has to show their data,” we evaluated the effectiveness of OA and SMART Recovery (SR) with problem drinkers in a randomized clinical trial. We recruited 189 heavy problem drinkers primarily through SMART Recovery’s web site and their online and in-person meetings. We randomly assigned them to: (1) OA alone, (2) OA+ attend SMART Recovery meetings (OA +SR), or to (3) attend SMART Recovery meetings (SR) only. Outcome measures included self-reported percent days abstinent, mean drinks per day when they did drink , and alcohol/drug related consequences. We also interviewed significant others to corroborate the participant’s self-report.

We predicted that: (1) All groups would reduce their drinking and alcohol/drug related consequences at follow-up compared to their baseline levels; (2) the OA groups would reduce their drinking and alcohol/drug related consequences more than the control group (SR).

There were several striking features of our participants. First, 60% of them were female. While this is consistent with the clinical trials of our other web applications like the Drinker’s Check-up (www.drinkerscheckup.com) and Moderate Drinking (www.moderatedrinking.com), it is significantly more than what one would predict given the prevalence of problem drinking in women versus men (35 vs. 65% respectively) in the epidemiological data. Second, this was a highly educated group with an average of 16 years of education. Third, while these folks were not seeking formal treatment, they had a level of alcohol problems comparable to the outpatient arm of Project MATCH.

At the 3 month follow-up both the intent-to-treat analyses and the actual use analyses showed highly significant improvement from baseline to follow-ups.  Mean within-subject effect sizes were large (d > .8) overall. There were, however, no significant differences between groups. Participants in all groups significantly increased their percent days abstinent from 44% to 72% (P<.001), decreased their mean drinks per drinking day from 8.0 to 4.6 (P<.001), and decreased their alcohol/drug-related problems (P<.001) by about 50%. These are clinically meaningful improvements in outcomes.

These outcomes indicate that both our Overcoming Addictions web app and attending SMART Recovery meetings and using their resources online (www.smartrecovery.org) were effective in helping people recover from their problem drinking.

These graphs reflect outcomes of the actual use analyses.

Advice for Mental Health Clinicians

A clinician recently sent me this email:

Dr. Willenbring,

I read an article in the New York Times from early this year discussing Effective Addiction Treatment that in part highlighted your comments and Alltyr's mission to be a 21st century model for addictions treatment.

As a therapist in an outpatient practice not specializing in addictions treatment--but who nevertheless encounters co-morbidity with substance abuse on a pretty regular basis--it can be confusing to know how to approach the psychosocial aspects of treatment. I believe in a multimodal approach for chronic forms of addiction but there are tons of options out there for my part in that process:  motivational enhancement therapy, cognitive-behavioral, contingency management interventions/motivational incentives, the matrix model, 12-step, DBT, family behavior therapy, interpersonal neurobiology, etc. There is so much out there it's dizzying, and I feel overwhelmed. There are some that seem more indicated for alcohol, others that seem better for stimulants, another for opioids. I've worked for agencies that are sold on one particular treatment for every type of substance abuser, and others that turn their therapists loose to use whatever they think best.

I want to use the best, empirically validated approaches and everyone seems to have an opinion on what that is. Where would you recommend I start, particularly for treatment options?

Here's my reply:

Hi Jxxxx,

It is indeed a confusing landscape out there, both for non-specialist clinicians and for patients and families. 

A good place to start is with the ASAM textbook on treatment of addictive disorders. It's coming out with a new edition (or it has just come out). Also, the American Psychiatric Association textbook is pretty good as an overall summary of evidence-based practice.

On an individual clinician level though it can be confusing. Here are some thoughts:

First, there is no ONE RIGHT WAY to overcome addictions. There are many different pathways. Our job is to help each person find his or her own best way.

Second, a skilled clinician is usually effective no matter the specific technique, as long as the clinician is focused on the patient, not the technique or path. Focus on general skills, such as empathy, reflective listening, unconditional positive regard, and instilling hope. There is no evidence that a specific technique is more effective than another, except in specific circumstances. The relationship is more important.

Third, be patient oriented. Take them where they are. Find out what they want, help them clarify their goals and how to reach them. Help them learn skills to achieve their goals, while also gently helping them realize that the ideal goal (use without consequences) is out of reach.

Finally, be patient and let them teach you about their disorder and its nature. Recovery is a two-steps-forward, one-step backward process. Trying and failing is a necessary step for most people, and the important thing is to accept that, learn from each step back, and then look forward. Persistence is the key. 

A couple of other things.

Never use the words denial, codependency, or enabling. Don't threaten, cajole or berate. Don't share your own experience unless it is (very) clearly in the best interests of the patient (it usually isn't). 

Never question their motivation to get better. I've never met an addict who liked being addicted. They all want to feel better, but sometimes it takes awhile to figure what the way forward is. 

Accept that you can't help everyone. Why should we be able to universally help everyone with a complex human affliction? Be humble, but hopeful and available. Never blame the patient/client for the failure of our treatments, which are modestly effective at best. People die of this disease, and too often we can't stop it or know how to help them. People die from all sorts of illnesses. It's no different to die of a dysregulation in our brain than in our heart, immune system or pancreas. We need to get over ourselves a little bit. We don't need to blame the person with the disease in order to protect ourselves from our inability to stop it. 

And keep working, and trying, and stay hopeful and alive and open hearted. That does the most of all.

Thanks for writing,

MW

Recovery Happens.

An analysis of an impressive and wide-sweeping study arrived in my email box this morning, via the wonderful folks at Drug and Alcohol Findings in the UK. For the study, recovery advocate William L White reviewed 415 scientific studies of recovery outcomes from clinically- and culturally-diverse populations, looking at research performed over the past century. Among the highlights, the author concludes from all of this data that recovery happens - at far greater rates than conventional wisdom would have us believe. In fact,  "Recovery is not an aberration achieved by a small and morally enlightened minority of addicted people. If there is a natural developmental momentum within the course of [these] problems, it is toward remission and recovery."

Some very hopeful words to start your day.

Below are some additional highlights. You can access the article here:  http://findings.org.uk/count/downloads/download.php?file=White_WL_24.txt and find great resources for treatment research and interventions here: http://findings.org.uk/index.php (the drug and alcohol matrices are a treasure trove of important research).

1 How many people are in recovery from substance use disorders in the United States? This was answered by extrapolating national estimates from the major governmental surveys of the course of alcohol and other drug use and related problems and from a 2010 recovery survey conducted by the Public Health Management Corporation in Philadelphia and six surrounding counties. Based on this analysis, the proportion of adults in the general US population in remission from substance use disorders ranges from 5.3% to 15.3%. These rates produce a conservative estimate of more than 25 million adults in remission from significant alcohol or drug problems in the United States and possibly up to 40 million.

2 What percentage of those who develop alcohol or drug problems eventually achieve remission/recovery? Of adults surveyed in the general population who once met lifetime criteria for substance use disorders, an average of 49.9% (53.9% in studies conducted since 2000) no longer meet those criteria. In community studies (ie, not sampling treatment populations only) reporting both remission rates and abstinence rates for substance use disorders, an average of 43.5% of people who have ever had these disorders achieved remission, but only 17.9% did so through complete abstinence.

3 What is the rate of remission/recovery for people whose problems are severe enough to warrant professional treatment? Across 276 substance use treatment follow-up studies of adult clinical samples, the average remission/recovery rate was 47.6% (50.3% in studies published since 2000). In studies with sample sizes of 300 or more and follow-up periods of five or more years – used as proxy for greater methodological sophistication – average remission/recovery rates were 46.4% and 46.3%, respectively. In the 50 adult clinical studies reporting both remission and abstinence rates, the average remission rate was 52.1%, and the average abstinence rate was 30.3%.This 21.8% difference appears to reflect the proportion in post-treatment follow-up studies who are using alcohol and/or other drugs asymptomatically or are experiencing problems not severe enough to meet diagnostic criteria for substance use disorders.

4 Does the rate of remission/recovery for adolescents following specialised treatment differ from that of adults? Yes. This analysis compares 276 adult substance use treatment outcome studies conducted between 1868 and 2011 with 60 adolescent substance use treatment outcome studies between 1979 and 2011. The average recovery/remission rate following specialty treatment for adolescents was 42% (35% for studies since 2000), compared to 47.6% for adults (50.3% for studies since 2000). Interpretation of this finding should be tempered by the greater number of adult studies and their larger sample sizes and much longer follow-up periods. While the high percentage of adolescents who report some alcohol or drug use in the months following treatment is discouraging, longer-term studies confirm post-treatment increases in abstinence, reductions in use, and gains in global health among treated adolescents. There is cause for optimism regarding adolescents' long-term prospects for recovery from substance use disorders.

5 How can local communities establish baseline remission/recovery prevalence data? To evaluate community-wide strategies by tracking changes in recovery prevalence over time, local communities can integrate recovery prevalence questions into regular community health surveys. A model for potential replication is the integration of recovery prevalence questions into the bi-annual community health survey conducted in Philadelphia and surrounding counties. Such baseline data are being used there and could be used in other communities to guide recovery-focused systems-transformation efforts and to evaluate planned interventions in particular geographical areas (eg, evaluating service needs by postcode/planning areas and matching treatment/recovery support resources to areas where problem severity is highest and recovery capital lowest).