Publications by Year: 2014

Baxter, L., Demitor, M., DuPont, C., DuPont, H., Fortner, N., Gitlow, S., Gold, M., et al. (2014). The new paradigm for recovery: Making Recovery – and Not Relapse – the Expected Outcome of Addiction Treatment (pp. 1-34) . A report of the John P. McGovern Symposium hosted by the Institute for Behavior and Health, Inc.
Kelly, J. F. (2014). The new science on AA and 12-step facilitation. The Carlat Report , 2 (4), 1-5.
Hoeppner, B. B., Hoeppner, S. S., & Kelly, J. F. (2014). Do young people benefit from AA as much, and in the same ways, as adult aged 30+? A moderated multiple mediation analysis. Drug and Alcohol Dependence , 143 (1), 181-188.Abstract


Background: Research has shown that participation in Alcoholics Anonymous (AA) confers significant recovery benefit to adults suffering from alcohol use disorder (AUD). Concerns persist, however, that AA may not work as well for younger adults, who tend to have shorter addiction histories, different social circumstances, and less spiritual/religious interest than adults. Methods: Secondary data analysis of Project MATCH, using a prospective, moderated multiple mediation analysis to test and compare six previously identified mechanisms of change in younger adults (n = 266) vs. adults aged 30+ (n = 1460). Nine clinical sites within the United States. Treatment-seeking adults (n = 1726) suffering from AUD who participated in 12 weeks of outpatient treatment and completed follow-ups at 3-, 9- and 15-months. AA attendance during treatment; mediators at 9 months; and outcomes [percentage of days abstinent (PDA) and drinks per drinking day (DDD)] at 15 months. Results: AA attendance was associated with improved drinking outcomes in both younger adults (PDA: F(1, 247) = 8.55, p < 0.01; DDD: F(1, 247) = 15.93, p < 0.01) and adults aged 30+ (PDA: F(1, 1311) = 86.58, p < 0.01; DDD: F(1, 1311) = 11.96, p < 0.01). Only two of the six hypothesized pathways (i.e., decreases in pro-drinking social networks, self-efficacy in social situations) appeared to work in younger adults. Conclusion: Unidentified mechanisms of behavior change that are mobilized by AA participation appear to be at work in young people. Once identified, these mechanisms may shed new light on how exactly AA confers similar benefits for young people and, more broadly, may enhance our understanding of recovery-related change for young adults that could yield novel intervention targets.


Kelly, J. F., & Greene, C. M. (2014). Where there’s a will there’s a way: A longitudinal investigation of the interplay between recovery motivation and self-efficacy in predicting treatment outcome. Psychology of Addictive Behaviors , 28 (3), 928-934. Publisher's VersionAbstract


The psychological construct of self-efficacy plays a key role in both general, as well as addiction-specific, models of health behavior change and is well supported empirically. As a predictor of treatment outcome it has proven useful; however, to further clarify the nature and role of self-efficacy in predicting the complexities of addiction recovery, it would seem crucial also to consider an individuals' motivation to carry out that future behavior, because the degree to which a measure of self-efficacy predicts behavior may be contingent upon whether that individual is also motivated to enact it. To this end, we tested an interaction model of self-efficacy and motivation on treatment outcome. Young adults (N = 302; M = 20 years; 74% male) undergoing residential substance use disorder treatment were assessed at treatment intake, discharge, and 3, 6, and 12 months postdischarge on self-efficacy (SE), motivation for sobriety (MS), and percent days abstinent (PDA). Hierarchical linear modeling (HLM) results revealed main effects for abstinence SE and MS across time, but a significant interaction was detected, indicating that the influence of SE on PDA depended on MS. Further analysis revealed that for patients high in SE the level of MS made a small, but significant, difference on PDA, whereas for those low in SE, high MS made a substantial difference, such that their outcome was not different than patients with high SE. Findings highlight conceptual nuances in SE theory; and, clinically, convey optimism that, even if a patient reports low confidence in their ability to remain abstinent, it does not necessarily follow that they will have poor outcome, especially if they have a strong recovery motivation.


Watson, J. A., Greene, C. M., & Kelly, J. F. (2014). Outpatient alcohol and drug treatment for adolescents with co-occurring conduct disorder. Alcoholism Treatment Quarterly , 32 (4), 393-415 . Taylor & Francis. Publisher's VersionAbstract


Conduct disorder (CD) commonly co-occurs among adolescents with substance use disorder (SUD) and complicates the clinical course of SUD. Although research has begun to investigate CD's impact on adolescent response to SUD treatment, comparatively little is known about the effects of outpatient SUD treatment on this population. This study examined how co-occurring CD influences SUD treatment response as well as longer-term outcomes. Adolescent outpatients (N = 126; M age = 16.7, 25% female) with (i.e., SUD-CD; n = 52), and without CD (SUD-only; n = 74), were compared at baseline. Multilevel mixed models tested group effects on percent days abstinent (PDA) and other clinical and continuing care variables during and following treatment at 6 and 12 months. At baseline, SUD-CD participants had significantly greater psychiatric symptoms, substance use consequences, problem severity, and comorbid internalizing disorders. Both groups changed similarly on measured variables during treatment; however, the sample overall showed increases in PDA and drops in psychiatric symptoms. Following treatment, there were no differences in PDA between groups (p = .44). Both groups showed lower rates of psychiatric symptoms and arrests in the year following treatment, though SUD-CD still reported more psychiatric symptoms (p = .01) and higher inpatient (p = .02) and outpatient treatment (p = .04) utilization than SUD-only. SUD-CD patients may require a more psychiatrically integrated treatment approach during outpatient SUD treatment and more assertive and aggressive continuing care to reduce psychiatric distress, decrease the risk of further hospitalizations, and increase quality of life.


Schuman-Olivier, Z., Greene, C. M., Bergman, B. G., & Kelly, J. F. (2014). Is residential treatment effective for opioid use disorders? A longitudinal comparison of treatment outcomes among opioid dependent, opioid misusing, and non-opioid using emerging adults with substance use disorder. Drug and Alcohol Dependence , 144, 178-185 . Elsevier. Publisher's VersionAbstract


BACKGROUND: Opioid misuse and dependence rates among emerging adults have increased substantially. While office-based opioid treatments (e.g., buprenorphine/naloxone) have shown overall efficacy, discontinuation rates among emerging adults are high. Abstinence-based residential treatment may serve as a viable alternative, but has seldom been investigated in this age group.

METHODS: Emerging adults attending 12-step-oriented residential treatment (N=292; 18-24 years, 74% male, 95% White) were classified into opioid dependent (OD; 25%), opioid misuse (OM; 20%), and no opiate use (NO; 55%) groups. Paired t-tests and ANOVAs tested baseline differences and whether groups differed in their during-treatment response. Longitudinal multilevel models tested whether groups differed on substance use outcomes and treatment utilization during the year following the index treatment episode.

RESULTS: Despite a more severe clinical profile at baseline among OD, all groups experienced similar during-treatment increases on therapeutic targets (e.g., abstinence self-efficacy), while OD showed a greater decline in psychiatric symptoms. During follow-up relative to OM, both NO and OD had significantly greater Percent Days Abstinent, and significantly less cannabis use. OD attended significantly more outpatient treatment sessions than OM or NO; 29% of OD was completely abstinent at 12-month follow-up.

CONCLUSIONS: Findings here suggest that residential treatment may be helpful for emerging adults with opioid dependence. This benefit may be less prominent, though, among non-dependent opioid misusers. Randomized trials are needed to compare more directly the relative benefits of outpatient agonist-based treatment to abstinence-based, residential care in this vulnerable age-group, and to examine the feasibility of an integrated model.


Kelly, J. F., Stout, R. L., Greene, C. M., & Slaymaker, V. (2014). Young adults, social networks, and addiction recovery: Post treatment changes in social ties and their role as a mediator of 12-step participation. PloS One , 9 (6), e100121 . Public Library of Science. Publisher's VersionAbstract


BACKGROUND: Social factors play a key role in addiction recovery. Research with adults indicates individuals with substance use disorder (SUD) benefit from mutual-help organizations (MHOs), such as Alcoholics Anonymous, via their ability to facilitate adaptive network changes. Given the lower prevalence of sobriety-conducive, and sobriety-supportive, social contexts in the general population during the life-stage of young adulthood, however, 12-step MHOs may play an even more crucial recovery-supportive social role for young adults, but have not been investigated. Greater knowledge could enhance understanding of recovery-related change and inform young adults' continuing care recommendations.

METHODS: Emerging adults (N = 302; 18-24 yrs; 26% female; 95% White) enrolled in a study of residential treatment effectiveness were assessed at intake, 1, 3, 6, and 12 months on 12-step attendance, peer network variables ("high [relapse] risk" and "low [relapse] risk" friends), and treatment outcomes (Percent Days Abstinent; Percent Days Heavy Drinking). Hierarchical linear models tested for change in social risk over time and lagged mediational analyses tested whether 12-step attendance conferred recovery benefits via change in social risk.

RESULTS: High-risk friends were common at treatment entry, but decreased during follow-up; low-risk friends increased. Contrary to predictions, while substantial recovery-supportive friend network changes were observed, this was unrelated to 12-step participation and, thus, not found to mediate its positive influence on outcome.

CONCLUSIONS: Young adult 12-step participation confers recovery benefit; yet, while encouraging social network change, 12-step MHOs may be less able to provide social network change directly for young adults, perhaps because similar-aged peers are less common in MHOs. Findings highlight the importance of both social networks and 12-step MHOs and raise further questions as to how young adults benefit from 12-step MHOs.


Kelly, J. F., & Greene, C. M. (2014). Toward an enhanced understanding of the psychological mechanisms by which spirituality aids recovery in Alcoholics Anonymous. Alcoholism Treatment Quarterly , 32 (2-3), 299-318 . Taylor & Francis. Publisher's VersionAbstract


Alcoholics Anonymous (AA) is based on a spiritual program of action. In keeping with AA's spiritually based recovery theory, rigorous studies have revealed that spirituality may be one of the mechanisms through which AA aids recovery. A question that has lingered, however, is how exactly does an increase in spiritual beliefs and practices translate into more abstinence and remission? To help answer this question, this article reviews theory and research related to AA and spirituality as a mechanism of behavior change and offers five possible psychological pathways that may help explain how increases in spirituality may translate into enhanced abstinence and remission rates.


Kelly, J. F., & Greene, C. M. (2014). Beyond motivation: Initial validation of the commitment to sobriety scale. Journal of Substance Abuse Treatment , 46 (2), 257-263 . Elsevier. Publisher's VersionAbstract


From an addiction treatment and recovery standpoint maladaptive motivational hierarchies lie at the core of the challenge in mobilizing salutary behavior change. Motivation has been conceptualized as dynamic, interactive and modifiable, as well as multidimensional. Measures of recovery motivation have been developed and validated, but are generally only modest and variable predictors of future behavior. A related, but potentially more potent, construct, is that of commitment to sobriety as it denotes a clearer re-ranking of motivational hierarchies such that the recovery task is now given a top priority potentially less susceptible to the risks associated with undulating future circumstance. This study investigated the psychometric properties of a novel commitment to sobriety scale (CSS). Results revealed a coherent, psychometrically valid, and reliable tool that outperformed an existing commitment to abstinence scale (ATAQ; J. Morgenstern, R.M. Frey, B.S. McCrady, E. Labouvie, & C.J. Neighbors, 1996) and a gold standard measure of motivation (SOCRATES; W.R. Miller & J.S. Tonigan, 1996). This study highlights commitment to sobriety as an important addiction construct. Researchers and theoreticians may find the CSS useful in helping to explain how individuals achieve recovery, and practitioners may find clinical utility in the CSS in helping identify patients in need of more intensive or alternative intervention.


Kazemi, D. M., Cochran, A. R., Kelly, J. F., Cornelius, J. B., & Belk, C. (2014). Integrating mHealth mobile applications to reduce high risk drinking among underage students. Health Education Journal , 73 (3), 262-273 . SAGE Publications. Publisher's VersionAbstract


Objective: College students embrace mobile cell phones (MCPs) as a primary communication and entertainment device. The aim of this study was to investigate college students’ perceptions toward using mHealth technology to deliver interventions to prevent high-risk drinking and associated consequences.

Design/setting: Four focus group interviews were conducted during the spring and fall of 2011 at a large public university in the southeastern United States of America (USA) to collect data on the applicability of mHealth technology to alcohol-prevention programmes. The participants were students currently enrolled in a face-to-face alcohol-prevention programme.

Method: Thematic analysis of the content in the transcriptions was used to analyse the focus group responses using a codebook.

Results: Four major themes emerged which were: (1) education and usability; (2) Skype capabilities; (3) enhanced social networking; and (4) use for tracking and feedback. All of the participants said they would join an alcohol-intervention programme that incorporated mHealth mobile technology as a primary mode of communication.

Conclusions: The positive responses to the use of mobile applications indicate that use of interactive, real-time technology would be valuable to college students. Given the cost of face-to-face delivery of interventions, the findings are encouraging and support further exploration of the application of mHealth technology. Mobile technologies (mHealth) could provide a more effective delivery of alcohol-intervention programmes and increase the accessibility, relevance, and value of alcohol-intervention programmes.


Greene, C. M., & Kelly, J. F. (2014). The prevalence of cannabis withdrawal and its influence on adolescents' treatment response and outcomes: A 12-month prospective investigation. Journal of Addiction Medicine , 8 (5), 359-367 . LWW. Publisher's VersionAbstract


BACKGROUND: Withdrawal, a diagnostic indicator of cannabis use disorder, is often minimized or ignored as a consequence of cannabis use, particularly among adolescents. This study aims to characterize cannabis withdrawal among adolescents in outpatient treatment for substance use disorder and evaluate the clinical significance of withdrawal as a predictor of substance-related outcomes.

METHODS: Adolescent outpatients (N = 127) reporting cannabis as their drug of choice (n = 90) were stratified by the presence of withdrawal and compared on demographic and clinical variables at treatment intake. Hierarchical linear models compared the effect of withdrawal on percentage days abstinent (PDA) and related outcomes over a 1-year follow-up period.

RESULTS: Adolescents reporting withdrawal (40%) were more likely to meet criteria for cannabis dependence, have higher levels of substance use severity, report more substance-related consequences, and have a mood disorder. Withdrawal was not associated with PDA over the follow-up period; however, this relationship was moderated by problem recognition such that adolescents reporting withdrawal and a drug problem improved at a greater rate with respect to PDA than those who did not recognize a problem with drugs and did not report withdrawal.

DISCUSSION: Withdrawal is common among adolescent outpatients and is associated with a more clinically severe profile. In this sample, all adolescents reporting withdrawal met criteria for cannabis dependence, suggesting that withdrawal is a highly specific indicator of cannabis use disorder. Although withdrawal does not seem to be independently associated with substance use outcomes posttreatment, moderating factors such as drug problem recognition should be taken into account when formulating treatment and continuing care plans.


Labbe, A. K., Slaymaker, V., & Kelly, J. F. (2014). Toward enhancing 12-step facilitation among young people: A systematic qualitative investigation of young adults' 12-step experiences. Substance Abuse , 35 (4), 399-407 . Taylor & Francis. Publisher's VersionAbstract


BACKGROUND: 12-Step Facilitation (TSF) interventions designed to enhance rates of engagement with 12-step mutual-help organizations (MHOs) have shown efficacy among adults, but research provides little guidance on how to adapt TSF strategies for young people.

METHODS: To inform TSF strategies for youth, this study used qualitative methods to investigate the self-reported experiences of 12-step participation, and reasons for nonattendance and discontinuation among young adults (18-24 years; N = 302). Responses to open-ended questions following residential treatment were coded into rationally derived domains.

RESULTS: Young adults reported that cohesiveness, belonging, and instillation of hope were the most helpful aspects of attending 12-step groups; meeting structure and having to motivate oneself to attend meetings were the most common aspects young adults liked least; logistical barriers and low recovery motivation and interest were the most common reasons for discontinued attendance; and perceptions that one did not have a problem or needed treatment were cited most often as reasons for never attending.

CONCLUSIONS: Findings may inform and enhance strategies intended to engage young people with community-based recovery-focused 12-step MHOs and ultimately improve recovery outcomes.


Bergman, B. G., Greene, C. M., Slaymaker, V., Hoeppner, B. B., & Kelly, J. F. (2014). Young adults with co-occurring disorders: Substance use disorder treatment response and outcomes. Journal of Substance Abuse Treatment , 46 (4), 420-428 . Elsevier. Publisher's VersionAbstract


Compared to other life stages, young adulthood (ages 18-24) is characterized by qualitative differences including the highest rates of co-occurring substance use and psychiatric disorders (COD). Little is known, however, regarding young adults' response to substance use disorder (SUD) treatment, especially those with COD. Greater knowledge in this area could inform and enhance the effectiveness and efficiency of SUD care for this patient population. The current study investigated differences between 141 COD and 159 SUD-only young adults attending psychiatrically-integrated residential SUD treatment on intake characteristics, during-treatment changes on clinical targets (e.g., coping skills; abstinence self-efficacy), and outcomes during the year post-discharge. Contrary to expectations, despite more severe clinical profiles at intake, COD patients showed similar during-treatment improvements on clinical target variables, and comparable post-treatment abstinence rates and psychiatric symptoms. Clinicians referring young adults with COD to specialized care may wish to consider residential SUD treatment programs that integrate evidence-based psychiatric services.


Bergman, B. G., Greene, C. M., Hoeppner, B. B., Slaymaker, V., & Kelly, J. F. (2014). Psychiatric comorbidity and 12‐step participation: A longitudinal investigation of treated young adults. Alcoholism: Clinical and Experimental Research , 38 (2), 501-510 . Wiley Online Library. Publisher's VersionAbstract


Background: Evidence indicates 12-step mutual-help organizations (MHOs), such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), can play an important role in extending and potentiating the recovery benefits of professionally-delivered addiction treatment among young adults with substance use disorders (SUD). However, concerns have lingered regarding the suitability of 12-step organizations for certain clinical subgroups, such as those with dual diagnosis (DD). This study examined the influence of diagnostic status (DD vs. SUD-only) on both attendance and active involvement (e.g., having a sponsor, verbal participation during meetings) in, and derived benefits from, 12-step MHOs following residential treatment.

Methods: Young adults (N = 296; 18-24 years old; 26% female; 95% Caucasian; 47% DD [based on structured diagnostic interview]), enrolled in a prospective naturalistic study of SUD treatment effectiveness, were assessed at intake, and 3, 6, and 12 months post-treatment on 12-step attendance/active involvement and percent days abstinent (PDA). T-tests and lagged, hierarchical linear models (HLM) examined the extent to which diagnostic status influenced 12-step participation and any derived benefits, respectively.

Results: For DD and SUD-only patients, post-treatment attendance and active involvement in 12-step organizations was similarly high. Overall, DD patients had significantly lower PDA relative to SUD-only patients. All patients appeared to benefit significantly from attendance and active involvement on a combined eight-item index. Regarding the primary effects of interest, significant differences did not emerge in derived benefit between DD and SUD-only patients for either attendance (p = .436) or active involvement (p = .062). Subsidiary analyses showed, however, that DD patients experienced significantly greater abstinence-related benefit from having a 12-step sponsor.

Conclusion: Despite concerns regarding the clinical utility of 12-step MHOs for DD patients, findings indicate that DD young adults participate and benefit as much as SUD-only patients, and may benefit more from high levels of active involvement, particularly having a 12-step sponsor. Future work is needed to clarify how active 12-step involvement might offset the additional recovery burden of a comorbid mental illness on substance use outcomes.


Kelly, J. F., Greene, M. C., & Bergman, B. G. (2014). Do drug dependent patients attending Alcoholics Anonymous rather than Narcotics Anonymous do as well? A prospective, lagged, matching analysis. Alcohol and Alcoholism , 49 (6), 645-653. Publisher's VersionAbstract


Aims: Alcoholics Anonymous (AA) is the most prevalent 12-step mutual-help organization (MHO), yet debate has persisted clinically regarding whether patients whose primary substance is not alcohol should be referred to AA. Narcotics Anonymous (NA) was created as a more specific fit to enhance recovery from drug addiction; however, compared with AA, NA meetings are not as ubiquitous. Little is known about the effects of a mismatch between individuals' primary substance and MHOs, and whether any incongruence might result in a lower likelihood of continuation and benefit. More research would inform clinical recommendations.

Method: Young adults (N = 279, M age 20.4, SD 1.6, 27% female; 95% White) in a treatment effectiveness study completed assessments at intake, and 3, 6, and 12 months post-treatment. A matching variable was created for ‘primary drug’ patients (i.e. those reporting cannabis, opiates or stimulants as primary substance; n = 198/279), reflecting the proportion of total 12-step meetings attended that were AA. Hierarchical linear models (HLMs) tested this variable's effects on future 12-step participation and percent days abstinent (PDA).

Results: The majority of meetings attended by both alcohol and drug patients was AA. Drug patients attending proportionately more AA than NA meetings (i.e. mismatched) were no different than those who were better matched to NA with respect to future 12-step participation or PDA.

Conclusion: Drug patients may be at no greater risk of discontinuation or diminished recovery benefit from participation in AA relative to NA. Findings may boost clinical confidence in making AA referrals for drug patients when NA is less available.