This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:
The primary objective of this review is to evaluate the efficacy of Alcoholics Anonymous mutual help groups, operated by peers, and TSF interventions, operated by professionals. Both will be evaluated relative to other interventions for AUD by examining their effects on abstinence, drinking intensity, and drinking‐related consequences. The secondary objective is to examine the healthcare utilization cost impact of Alcoholics Anonymous attendance and of TSF.
In this review, Alcoholics Anonymous attendance and TSFs will be compared with the following interventions.
The European Pain Federation EFIC, the International Association for Hospice and Palliative Care, International Doctors for Healthier DrugPolicies, the Swiss Romandy College for Addiction Medicine, the Swiss Society of Addiction Medicine, and the World Federation for the Treatment of Opioid Dependence called on medical journals to ensure that authors always use terminology that is neutral, precise, and respectful in relation to the use of psychoactive substances. It has been shown that language can propagate stigma, and that stigma can prevent people from seeking help and influence the effectiveness of social and public-health policies. The focus of using appropriate terminology should extend to all patients who need controlled medicines, avoiding negative wording. A narrow focus on a few terms and medical communication only should be avoided. The appropriateness of terms is not absolute and indeed varies between cultures and regions and over time. For this reason, it is important that communities establish their own consensus of what is 'neutral', 'precise', and 'respectful'. We identified twenty-three problematic terms (most of them we suggest avoiding) and their possible alternatives. The use of appropriate language improves scientific quality of articles and increases chances that patients will receive the best treatment and that government policies on psychoactive substance policies will be rational.
BACKGROUND: It has been long established that achieving recovery from an alcohol or other drug use disorder is associated with increased biobehavioral stress. To enhance the chances of recovery, a variety of psychological, physical, social, and environmental resources, known as "recovery capital", are deemed important as they can help mitigate this high stress burden. A 50-item measure of recovery capital was developed (Assessment of Recovery Capital [ARC]), with 10 subscales; however, a briefer version could enhance further deployment in research and busy clinical/recovery support service settings. To help increase utility of the measure, the goal of the current study was to create a shorter version using Item Response Theory models.
METHOD: Items were pooled from the original treatment samples from Scotland and Australia (N=450) for scale reduction. A reduced version was tested in an independent sample (N=123), and a Receiver Operating Characteristic Curve was constructed to determine optimal cut-off for sustained remission (>12months abstinence).
RESULTS: An abbreviated 10-item measure of recovery capital captured item representation from all 10 original subscales, was invariant across participant's locality and gender, had high internal consistency (α=.90), concurrent validity with the original measure (rpb=.90), and predictive validity with sustained remission using a cut-off score of 47.
CONCLUSION: The brief assessment of recovery capital 10-item version (BARC-10) concisely measures a single unified dimension of recovery capital that may have utility for researchers, clinicians, and recovery support services.
BACKGROUND AND AIMS: The integration of 12-Step philosophy and practices is common in adolescent substance use disorder (SUD) treatment programs, particularly in North America. However, although numerous experimental studies have tested 12-Step facilitation (TSF) treatments among adults, no studies have tested TSF-specific treatments for adolescents. We tested the efficacy of a novel integrated TSF.
DESIGN: Explanatory, parallel-group, randomized clinical trial comparing 10 sessions of either motivational enhancement therapy/cognitive-behavioral therapy (MET/CBT; n = 30) or a novel integrated TSF (iTSF; n = 29), with follow-up assessments at 3, 6 and 9 months following treatment entry.
SETTING: Out-patient addiction clinic in the United States.
PARTICIPANTS: Adolescents [n = 59; mean age = 16.8 (1.7) years; range = 14-21; 27% female; 78% white].
INTERVENTION AND COMPARATOR: The iTSF integrated 12-Step with motivational and cognitive-behavioral strategies, and was compared with state-of-the-art MET/CBT for SUD.
MEASUREMENTS: Primary outcome: percentage days abstinent (PDA); secondary outcomes: 12-Step attendance, substance-related consequences, longest period of abstinence, proportion abstinent/mostly abstinent, psychiatric symptoms.
FINDINGS: Primary outcome: PDA was not significantly different across treatments [b = 0.08, 95% confidence interval (CI) = -0.08 to 0.24, P = 0.33; Bayes' factor = 0.28).
SECONDARY OUTCOMES: During treatment, iTSF patients had substantially greater 12-Step attendance, but this advantage declined thereafter (b = -0.87; 95% CI = -1.67 to 0.07, P = 0.03). iTSF did show a significant advantage at all follow-up points for substance-related consequences (b = -0.42; 95% CI = -0.80 to -0.04, P < 0.05; effect size range d = 0.26-0.71). Other secondary outcomes did not differ significantly between treatments, but effect sizes tended to favor iTSF. Throughout the entire sample, greater 12-Step meeting attendance was associated significantly with longer abstinence during (r = 0.39, P = 0.008), and early following (r = 0.30, P = 0.049), treatment.
CONCLUSION: Compared with motivational enhancement therapy/cognitive-behavioral therapy (MET/CBT), in terms of abstinence, a novel integrated 12-Step facilitation treatment for adolescent substance use disorder (iTSF) showed no greater benefits, but showed benefits in terms of 12-Step attendance and consequences. Given widespread use of combinations of 12-Step, MET and CBT in adolescent community out-patient settings in North America, iTSF may provide an integrated evidence-based option that is compatible with existing practices.
BACKGROUND: Opioid overdose deaths have become a major public health crisis. While efforts have focused mostly on helping opioid-addicted individuals directly, family members suffer also from the grave and enduring unpredictability associated with opioid addiction and often play a vital role in helping addicted loved ones access care. Little is known, however, about resources to help affected family members. Here we describe results from the first quantitative and qualitative investigation of a free and growing support organization for family members of addicted individuals ("Learn to Cope" [LTC]; www.learn2cope.org), organized around three key questions: 1. Who participates, how often, and in what ways? 2. What are the demographic and clinical histories of their addicted loved-ones? 3. How do participants benefit?
METHOD: Survey with LTC members at meetings and online (N=509; 95% participation rate).
RESULTS: 1. Participants were primarily middle-aged mothers (77%) of opioid-addicted adult male children, attending LTC meetings several times per month, using LTC online resources several times a week, and meeting with LTC members between meetings. 2. Their addicted loved-ones were mostly male (73%), addicted to opioids (88%), with a criminal history (70%), with just under half (41%) having suffered at least one prior overdose. Almost three-quarters (71%), however, reported their loved one was "in recovery", with 30% having a year or more. 3. Benefits since beginning participation included gains in understanding and coping with addiction, feeling better able to help and communicate with their loved-one, and reductions in self-blame and stress. Of members trained in Narcan administration (66%), 86% had received training at LTC meetings; LTC members reported having deployed Narcan for over 44 overdose reversals.
CONCLUSION: The growing availability of LTC may provide a needed source of support and information for family members of opioid-addicted loved-ones and may help reduce overdose deaths through Narcan training and distribution.
BACKGROUND: Alcohol and other drug (AOD) problems confer a global, prodigious burden of disease, disability, and premature mortality. Even so, little is known regarding how, and by what means, individuals successfully resolve AOD problems. Greater knowledge would inform policy and guide service provision.
METHOD: Probability-based survey of US adult population estimating: 1) AOD problem resolution prevalence; 2) lifetime use of "assisted" (i.e., treatment/medication, recovery services/mutual help) vs. "unassisted" resolution pathways; 3) correlates of assisted pathway use. Participants (response=63.4% of 39,809) responding "yes" to, "Did you use to have a problem with alcohol or drugs but no longer do?" assessed on substance use, clinical histories, problem resolution.
RESULTS: Weighted prevalence of problem resolution was 9.1%, with 46% self-identifying as "in recovery"; 53.9% reported "assisted" pathway use. Most utilized support was mutual-help (45.1%,SE=1.6), followed by treatment (27.6%,SE=1.4), and emerging recovery support services (21.8%,SE=1.4), including recovery community centers (6.2%,SE=0.9). Strongest correlates of "assisted" pathway use were lifetime AOD diagnosis (AOR=10.8[7.42-15.74], model R2=0.13), drug court involvement (AOR=8.1[5.2-12.6], model R2=0.10), and, inversely, absence of lifetime psychiatric diagnosis (AOR=0.3[0.2-0.3], model R2=0.10). Compared to those with primary alcohol problems, those with primary cannabis problems were less likely (AOR=0.7[0.5-0.9]) and those with opioid problems were more likely (AOR=2.2[1.4-3.4]) to use assisted pathways. Indices related to severity were related to assisted pathways (R2<0.03).
CONCLUSIONS: Tens of millions of Americans have successfully resolved an AOD problem using a variety of traditional and non-traditional means. Findings suggest a need for a broadening of the menu of self-change and community-based options that can facilitate and support long-term AOD problem resolution.
INTRODUCTION: Smartphone apps are emerging as a promising tool to support recovery from and prevention of problematic alcohol use, yet it is unclear what type of apps are currently available in the public domain, and to what degree these apps use interactive tailoring or other dynamic features to meet users' specific needs.
METHODS: We conducted a content analysis of Android apps for managing drinking available on Google Play (n = 266), downloaded between November 21, 2014 and June 25, 2015. We recorded app popularity (> 10,000 downloads) and user-rated quality (number of stars) from Google Play, and coded the apps on three domains (basic descriptors, functionality, use of dynamic features).
RESULTS: In total, the reviewed 266 apps were downloaded at least 2,793,567 times altogether. The most common types of app were BAC calculators (37%), information provision apps (37%), tracking calendars (24%), and motivational tools (21%). Most apps were free (65%) or low in cost (mean = $3.76; SD = $5.80). Many apps provided at least some level of tailored feedback (60%), but the extent of tailoring was limited. Use of other dynamic features (i.e., push notifications, passive data collection) was largely absent. Univariate models predicting app popularity (i.e., > 10,000 downloads vs. not) and user-rated quality (i.e., star rating) indicated that tailoring was positively related to popularity (OR = 2.41 [1.30–4.46]), and the existence of time-based tailoring (e.g., tracking) was related to quality (b = 0.48 [0.19–0.77]).
CONCLUSIONS: These apps have a wide public health reach with > 2.7 million total combined downloads to date. A wide variety of apps exist, allowing persons interested in using apps to help them manage their drinking to choose from numerous types of supports. Tailoring, while related favorably to an app's popularity and user-rated quality, is limited in publicly available apps.
Research shows that digital social network sites (SNSs) may be valuable platforms to effect health behavior change. Little is known specifically about their ability to help address alcohol and other drug problems. This gap is noteworthy, given that individuals are already participating in existing, recovery-specific SNSs (hereafter referred to as recovery SNSs): online communities with the functionality of conventional SNSs (e.g., Facebook) that focus on substance use disorder (SUD) recovery. For example, InTheRooms.com (ITR) is a large, well-known recovery SNS that is available for free 24 hr/day via website and mobile smartphone applications. It offers recovery tools within a digital social milieu for over 430,000 registered users. To augment the knowledge base on recovery SNS platforms, we conducted an online survey of 123 ITR participants (M = 50.8 years old; 56.9% female; 93.5% White; M = 7.3 years of abstinence, range of 0-30 years; 65% cited alcohol as their primary substance). Respondents engaged with ITR, on average, for about 30 min/day several times each week. Daily meditation prompts and live online video meetings were the most commonly utilized resources. Participants generally endorsed ITR as a helpful platform, particularly with respect to increased abstinence/recovery motivation and self-efficacy. Compared to individuals abstinent for 1 or more years, those abstinent less than 1 year (including nonabstinent individuals) showed similar rates of engagement with ITR activities and similar levels of perceived benefit. Our findings suggest that longitudinal studies are warranted to examine the clinical utility of ITR and other recovery SNSs as SUD treatment adjuncts and/or recovery self-management tools. (PsycINFO Database Record (c) 2017 APA, all rights reserved).
BACKGROUND: Only 10% of people with substance use disorder (SUD) receive treatment, partially due to inadequate access to specialty SUD care and limited management within primary care. "Recovery coaches" (RCs), peers sharing the lived experience of addiction and recovery, are increasingly being integrated into primary care to help reach and treat people experiencing SUD, yet little is known about how their role should be defined or about their clinical integration and impact.
METHODS: Semistructured interviews with RCs (n = 5) and their patients (n = 16) were used to explore patient and RC perspectives on the RC role. Maximum variation sampling was employed to select patients who displayed diversity across gender, RC, housing status, and number of contacts with an RC. Patients were sampled until no new concepts emerged from additional interviews, and a semistructured interview guide was used for data collection. To analyze interview transcripts, the constant comparative method was used to develop and assign inductively developed codes. Two coders separately coded all transcripts and reconciled code assignments.
RESULTS: Four core RC activities were identified: system navigation, supporting behavior change, harm reduction, and relationship building. Across these activities, benefits of the RC role emerged, including accessibility, shared experiences, motivation of behavior change, and links to social services. Challenges of the RC model were also evident: patient discomfort with asking for help, lack of clarity in RC role, and tension within the care team.
CONCLUSIONS: These findings shed light on RCs in primary care. Many patients and coaches perceived that RCs play a valuable role within primary care, providing both tangible system navigation and intangible, social support that promote recovery and might not otherwise be available. Enhanced communication between RCs and health center leadership in defining the RC role may help resolve ambiguity and related tensions between RCs and care team members.
Objective: Compared with older adults, emerging adults (18-29 years old) entering treatment typically have less severe alcohol use consequences. Also, their unique clinical presentations (e.g., modest initial abstinence motivation) and developmental contexts (e.g., drinking-rich social networks) may make a straightforward implementation of treatments developed for adults less effective. Yet, this has seldom been examined empirically. This study was a secondary analysis of Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) data examining (a) overall differences between emerging adults and older adults (≥30 years old) on outcomes during treatment and at 1-year follow-up, and (b) whether emerging adults had poorer outcomes on any of the three Project MATCH treatments in particular.
Method: Participants were 267 emerging adults and 1,459 older adults randomly assigned to individually delivered cognitive-behavioral therapy (CBT), motivational enhancement therapy (MET), or 12-step facilitation (TSF). Multilevel growth curve models tested differences on percentage of days abstinent (PDA) and drinks per drinking day (DDD) by age group and treatment assignment.
Results: During treatment, compared with older adults, emerging adults reported more DDD but similar PDA. Further, emerging adults assigned to TSF had less PDA and more DDD than emerging adults and older adults assigned to CBT or MET during treatment (i.e., emerging adults in TSF has poorer outcomes initially), but this matching effect was not evident at 1-year follow-up.
Conclusions: This study is among the first to test age group differences across three psychosocial interventions shown to be efficacious treatments for alcohol use disorder. Although emerging adults generally did as well as their older counterparts, they may require a more developmentally sensitive approach to bolster TSF effects during treatment.
BACKGROUND: Having high-risk, substance-using friends is associated with young adult substance use disorder (SUD) relapse. It is unclear, however, whether it is the total number of high-risk friends, or the amount of time spent with high-risk friends that leads to relapse. Unclear also, is to what extent low-risk friends buffer risk. This study examined the influence of number of high-risk and low-risk friends, and the amount time spent with these friends on post-treatment percent days abstinent (PDA).
METHOD: Young adult inpatients (N=302) were assessed at intake, and 3, 6, and 12 months on social network measures and PDA. Mixed models tested for effects of number of high- and low-risk friends, and time spent with these friends on PDA, and for net-risk friend effects to test whether low-risk friends offset risk.
RESULTS: Within and across assessments, number of, and time spent with high-risk friends was negatively associated with PDA, while the inverse was true for low-risk friends. Early post-treatment, time spent with friends more strongly predicted PDA than number of friends. Participants were more deleteriously affected by time with high-risk friends the longer they were out of treatment, while contemporaneously protection conferred by low-risk friends increased. This interaction effect, however, was not observed with number of high- or low-risk friends, or number of friends net-risk.
CONCLUSIONS: Young adult SUD patients struggling to break ties with high-risk friends should be encouraged to minimize time with them. Clinicians should also encourage patients to grow their social network of low-risk friends.
PURPOSE: The usefulness of mobile technology in supporting smoking cessation has been demonstrated, but little is known about how smartphone apps could best be leveraged. The purpose of this paper is to describe the program of research that led to the creation of a smoking cessation app for non-daily smokers, so as to stimulate further ideas to create "smart" smartphone apps to support health behavior change.
METHOD: Literature reviews to evaluate the appropriateness of the proposed app, content analyses of existing apps, and smoking cessation sessions with non-daily smokers (n = 38) to inform the design of the app.
RESULTS: The literature reviews showed that (1) smoking cessation apps are sought after by smokers, (2) positive affect plays an important role in smoking cessation, (3) short, self-administered exercises consistently bring about enduring positive affect enhancements, and (4) low treatment-seeking rates of non-daily smokers despite high motivation to quit indicate a need for novel smoking cessation support. Directed content analyses of existing apps indicated that tailoring, two-way interactions, and proactive features are under-utilized in existing apps, despite the popularity of such features. Conventional content analyses of audio-recorded session tapes suggested that difficulty in quitting was generally linked to specific, readily identifiable occasions, and that social support was considered important but not consistently sought out.
CONCLUSION: The "Smiling Instead of Smoking" (SIS) app is an Android app that is designed to act as a behavioral, in-the-pocket coach to enhance quitting success in non-daily smokers. It provides proactive, tailored behavioral coaching, interactive tools (e.g., enlisting social support), daily positive psychology exercises, and smoking self-monitoring.
Clinical guidelines recommend Self-Management and Recovery Training (SMART Recovery) and 12-step models of mutual aid as important sources of long-term support for addiction recovery. Methodologically rigorous reviews of the efficacy and potential mechanisms of change are available for the predominant 12-step approach. A similarly rigorous exploration of SMART Recovery has yet to be undertaken. We aim to address this gap by providing a systematic overview of the evidence for SMART Recovery in adults with problematic alcohol, substance, and/or behavioral addiction, including (i) a commentary on outcomes assessed, process variables, feasibility, current understanding of mental health outcomes, and (ii) a critical evaluation of the methodology. We searched six electronic peer-reviewed and four gray literature databases for English-language SMART Recovery literature. Articles were classified, assessed against standardized criteria, and checked by an independent assessor. Twelve studies (including three evaluations of effectiveness) were identified. Alcohol-related outcomes were the primary focus. Standardized assessment of nonalcohol substance use was infrequent. Information about behavioral addiction was restricted to limited prevalence data. Functional outcomes were rarely reported. Feasibility was largely indexed by attendance. Economic analysis has not been undertaken. Little is known about the variables that may influence treatment outcome, but attendance represents a potential candidate. Assessment and reporting of mental health status was poor. Although positive effects were found, the modest sample and diversity of methods prevent us from making conclusive remarks about efficacy. Further research is needed to understand the clinical and public health utility of SMART as a viable recovery support option.
(PsycINFO Database Record (c) 2017 APA, all rights reserved).
BACKGROUND: Alcoholics Anonymous (AA) is a world-wide recovery mutual-help organization that continues to arouse controversy. In large part, concerns persist because of AA's ostensibly quasi-religious/spiritual orientation and emphasis. In 1990 the United States' Institute of Medicine called for more studies on AA's effectiveness and its mechanisms of behavior change (MOBC) stimulating a flurry of federally funded research. This paper reviews the religious/spiritual origins of AA and its program and contrasts its theory with findings from this latest research.
METHOD: Literature review, summary and synthesis of studies examining AA's MOBC.
RESULTS: While AA's original main text ('the Big Book', 1939) purports that recovery is achieved through quasi-religious/spiritual means ('spiritual awakening'), findings from studies on MOBC suggest this may be true only for a minority of participants with high addiction severity. AA's beneficial effects seem to be carried predominantly by social, cognitive and affective mechanisms. These mechanisms are more aligned with the experiences reported by AA's own larger and more diverse membership as detailed in its later social, cognitive and behaviorally oriented publications (e.g. Living Sober, 1975) written when AA membership numbered more than a million men and women.
CONCLUSIONS: Alcoholics Anonymous appears to be an effective clinical and public health ally that aids addiction recovery through its ability to mobilize therapeutic mechanisms similar to those mobilized in formal treatment, but is able to do this for free over the long term in the communities in which people live.
BACKGROUND: Substance use disorders (SUDs) are highly prevalent among primary care patients. One evidence-based, cost-effective referral option is ubiquitous mutual help organizations (MHOs) such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and SMART Recovery; however, little is known about how to effectively increase trainee knowledge and confidence with these referrals. The primary aim of this study was to evaluate whether a single 45-minute combined lecture and role play-based didactic for primary care residents could enhance knowledge, improve attitudes, and bolster confidence in referring patients with addictions to community MHOs.
METHODS: The authors developed a 45-minute lecture and role play addressing the evidence for MHOs, their respective background/content, and how to make effective referrals. Participants were administered a brief survey of their MHO-related knowledge, attitudes, and confidence before and after the session to evaluate the didactic impact.
RESULTS: Participants were 55 primary care and categorical internal medicine residents divided among postgraduate year 1 (PGY1; 27.3%), PGY2 (38.2%), and PGY3 (34.5%). They had a mean age of 29 (SD = 2.62); 49% were female, 69% were Caucasian, and 78% reported some religious affiliation. Participants' subjective knowledge about MHOs increased significantly (P < .001), as did their confidence in making referrals (P < .001). Changes in participants' attitudes about the importance of MHOs in aiding successful addiction recovery approached significance (P = .058). The proportion of participants with correct responses to each of 4 knowledge-based questions increased substantially.
CONCLUSIONS: Primary care and internal medicine residents reported variable baseline knowledge of MHOs and confidence in making referrals, both of which were improved in response to a 45-minute didactic. Role play may be a useful supplementary tool in enhancing residents' knowledge and skill in treating patients with SUD.
KEYWORDS:Alcoholics Anonymous; Substance use disorder; medical education; mutual help; self-help groups; substance addiction