Kelly, J. F., Worley, M. J., & Yeterian, J. (2019). Twelve-Step Approaches. In S. A. Brown & R. Zucker (Ed.), The Oxford Handbook of Adolescent Substance Abuse (pp. 731-748) . Oxford University Press.Abstract
Twelve-step approaches to addressing substance use disorder (SUD) are unique in the treatment field in that they encompass professionally led, as well as peer-led, intervention methods. Also, in contrast to most professional treatments that have emerged from scientific theories and empirical data (e.g., cognitive-behavioral treatments), 12-step approaches have been derived, in large part, from the collective addiction and recovery experiences of laymen. Despite this, 12-step approaches have become influential in tackling SUD, with research demonstrating the clinical utility of employing such approaches among adults, and increasingly, among youth. Findings among adolescent samples indicate community 12-step mutual-help organizations, in particular, may provide a beneficial recovery-supportive social context during a life stage where such support is rare.
Substance use, misuse, and disorders (SUDs) are estimated to cost the United States over $500 billion annually. While there are effective SUD behavioral interventions and treatments, there is mounting evidence that technology‐based, digital recovery support services (D‐RSS) have the potential to prevent SUD, complement formal treatment, and improve individual recovery‐related outcomes. This preregistered systematic review focuses on D‐RSS that provide SUD recovery support through websites, smartphone applications, recovery social network sites, or any combination thereof. Data sources included studies found in searching CINAHL Plus (EBSCO), EMBASE, MEDLINE (EBSCO), Index Medicus/MEDLINE (NLM), Psychology & Behavioral Sciences Collection (EBSCO), PsycINFO (ProQuest), ProQuest Psychology Journals (ProQuest), and retrieved references. Observational, mixed‐methods, qualitative, or experimental studies, published in English, between January 1985 and January 2019, that characterized users and recovery‐related outcomes of any D‐RSS were included. The initial search yielded 5,278 abstracts. After removing duplicates, as well as reviewing titles and abstracts and removing studies not indicating an examination of recovery (i.e., treatment or prevention focused) and digital supports, 78 abstracts remained. Final included studies (n = 22) characterized international users of multiple D‐RSS types, including websites, digital recovery forums, recovery social networking sites, smartphone applications, and short messaging service texting programs. Experimental evidence was lacking as most studies were observational or qualitative in nature (n = 18). The review suggests that the evidence base for most D‐RSS is still lacking in terms of demonstrating benefit for recovery‐related outcomes. Descriptively, D‐RSS have high usage rates among engaged participants, across a range of SUD and recovery typologies and phenotypes, with 11% of U.S. adults who have resolved a SUD reporting lifetime engaging with at least one D‐RSS. D‐RSS deployment can help ameliorate barriers related to accessibility and availability of more traditional recovery supports, and may well be a valuable tool in addressing SUD and supporting recovery as uptake increases across the United States.
BACKGROUND: Alcohol and other drug (AOD) problems are commonly depicted as chronically relapsing, implying multiple recovery attempts are needed prior to remission. Yet, although a robust literature exists on quit attempts in the tobacco field, little is known regarding patterns of cessation attempts related to alcohol, opioid, stimulant, or cannabis problems. Greater knowledge of such estimates and the factors associated with needing fewer or greater attempts may have utility for health policy and clinical communication efforts and approaches.
METHODS: Cross-sectional, nationally representative survey of U.S. adults (N = 39,809) who reported resolving a significant AOD problem (n = 2,002) and assessed on number of prior serious recovery attempts, demographic variables, primary substance, clinical histories, and indices of psychological distress and well-being.
RESULTS: The statistical distribution of serious recovery attempts was highly skewed with a mean of 5.35 (SD = 13.41) and median of 2 (interquartile range [IQR] = 1 to 4). Black race, prior use of treatment and mutual-help groups, and history of psychiatric comorbidity were associated with higher number of attempts, and more attempts were associated independently with greater current distress. Number of recovery attempts did not differ by primary substance (e.g., opioids vs. alcohol).
CONCLUSIONS: Estimates of recovery attempts differed substantially depending on whether the mean (5.35 recovery attempts) or median (2 recovery attempts) was used as the estimator. Implications of this are that the average may be substantially lower than anticipated because cultural expectations are often based on AOD problems being "chronically relapsing" disorders implicating seemingly endless tries. Depending on which one of these estimates is reported in policy documents or communicated in public health announcements or clinical settings, each may elicit varying degrees of help-seeking, hope, motivation, and the use of more assertive clinical approaches. The more fitting, median estimate of attempts should be used in clinical and policy communications given the distribution.
KEYWORDS: Alcohol Use Disorder; Opioid Use Disorder; Quit Attempts; Recovery; Remission
INTRODUCTION: Smoking cessation interventions for nondaily smokers are needed. The current study explores the fit of the text-messaging intervention SmokefreeTXT for nondaily smokers.
METHODS: Adult nondaily smokers (N = 32; mean age = 35 ± 12, 64% female, 53% non-Hispanic White) were enrolled in SmokefreeTXT. SmokefreeTXT usage data were recorded passively, theorized mechanisms of change were assessed at baseline and 2, 6, and 12 weeks after the chosen quit day, and EMA protocols captured real-time cigarette reports at baseline, and during the first two weeks after the quit day.
RESULTS: Most participants completed the SmokefreeTXT program and responded to system-initiated inquiries, but just-in-time interaction with the program was limited. In retrospective recall at treatment end, content of the text-messages was rated as "neutral" to "helpful." Within-person change was observed in theorized mechanisms, with less craving (p < 0.01), increased abstinence self-efficacy (external: p < 0.01; internal: p < 0.01), and poorer perceptions of pros of smoking (psychoactive benefits: p < 0.01, pleasure p < 0.01; and pros: p < 0.01) reported after SmokefreeTXT initiation compared to baseline. Exploratory analyses of real-time reports of smoking (225 cigarette reports in N = 17 who relapsed) indicated that cigarettes smoked in the first two weeks after quitting were more likely to occur to reduce craving (OR = 2.21[1.21-3.72]), and less likely to occur to socialize (OR = 0.06[0.01-0.24]), between 19:00 and 23:00 (OR = 0.34[0.17-0.66]), and on Saturdays (OR = 0.59[0.35-0.99]) than prior to quitting.
CONCLUSIONS: While well accepted by nondaily smokers, SmokefreeTXT could potentially be improved by targeting cons of smoking, enhancing engagement with the just-in-time component of SmokefreeTXT, and tweaking the timing of text-messages.
KEYWORDS: Smoking cessation; mHealth; mechanisms of change; mobile health; text-messaging
Peer recovery support services (PRSS) are increasingly being employed in a range of clinical settings to assist individuals with substance use disorder (SUD) and co-occurring psychological disorders. PRSS are peer-driven mentoring, education, and support ministrations delivered by individuals who, because of their own experience with SUD and SUD recovery, are experientially qualified to support peers currently experiencing SUD and associated problems. This systematic review characterizes the existing experimental, quasi-experimental, single- and multi-group prospective and retrospective, and cross-sectional research on PRSS. Findings to date tentatively speak to the potential of peer supports across a number of SUD treatment settings, as evidenced by positive findings on measures including reduced substance use and SUD relapse rates, improved relationships with treatment providers and social supports, increased treatment retention, and greater treatment satisfaction. These findings, however, should be viewed in light of many null findings to date, as well as significant methodological limitations of the existing literature, including inability to distinguish the effects of peer recovery support from other recovery support activities, heterogeneous populations, inconsistency in the definitions of peer workers and recovery coaches, and lack of any, or appropriate comparison groups. Further, role definitions for PRSS and the complexity of clinical boundaries for peers working in the field represent important implementation challenges presented by this novel class of approaches for SUD management. There remains a need for further rigorous investigation to establish the efficacy, effectiveness, and cost-benefits of PRSS. Ultimately, such research may also help solidify PRSS role definitions, identify optimal training guidelines for peers, and establish for whom and under what conditions PRSS are most effective.
Objectives: The medical sequalae of alcohol and other drug (AOD) problems exact a prodigious personal and societal cost, but little is known about the specific prevalence of such medical problems, and their relationship to quality of life and indices of well-being among those recovering from problematic AOD use. To better characterize the lifetime physical disease burden, this study investigated the prevalence of medical conditions commonly caused or exacerbated by excessive and chronic AOD exposure in a nationally representative sample of US adults in AOD problem recovery. Comparisons were made to the general US population. Demographic and clinical correlates of disease prevalence were also investigated along with the relationship between distinct medical conditions and indices of quality of life/well-being.
Methods: Cross-sectional nationally representative survey of the US adult population who report resolving an AOD problem (n = 2002). Weighted lifetime prevalence of common medical conditions were estimated and compared to the US population. Demographic and clinical correlates of medical conditions, and also overall disease burden, were estimated using logistic regression.
Results: Relative to the general population, prevalence of hepatitis C, chronic obstructive pulmonary disease, heart disease, and diabetes were elevated. Likelihood of having a lifetime diagnosis of a specific disease was related to primary substance used and sex. Quality of life was lower among those with physical disease histories relative to those without.
Conclusions: Findings highlight the increased medical burden associated with AOD problems, and speak to the need for earlier and more sustained intervention for AOD problems, greater integration of addiction treatment and primary health care, and longitudinal research to explore the complex, dynamic relationships between AOD use and physical disease.
BACKGROUND: Due to shame and fear of discrimination, individuals in, or seeking, recovery from alcohol and other drug (AOD) problems often struggle with whether, when, and to whom to disclose information regarding their AOD histories and recovery status. This can serve as a barrier to obtaining needed recovery support. Consequently, disclosure may have important implications for recovery trajectories, yet is poorly understood.
DESIGN AND SAMPLE: Cross-sectional, U.S. nationally-representative survey conducted in 2016 among individuals with resolved AOD problems (N = 1987) investigated disclosure comfort and whether disclosure comfort differed by time since problem resolution, disclosure recipient (i.e., with interpersonal intimacy), or primary substance (i.e., alcohol [51%], cannabis [11%], opioids [5%], or "other" [33%]). Predictors of disclosure comfort were also examined. Data were analyzed using LOWESS analyses, analyses of variance, and regression.
RESULTS: Overall, longer time since problem resolution was associated with greater disclosure comfort. In general, participants reported greater comfort with disclosure to family and friends, and less comfort with disclosure to co-workers, to first-time acquaintances, in public settings, and in the media, but these effects varied by primary drug with participants who had problems with alcohol and "other" drugs having significantly more disclosure comfort than those who had problems with opioids.
CONCLUSION: Dimensions of time since AOD problem resolution, interpersonal intimacy, and primary drug are significantly associated with disclosure comfort. Individuals seeking recovery may benefit from more formal coaching around disclosure, particularly those with primary opioid problems, but further research is needed to determine the desire for and effects of such coaching among those seeking recovery.
KEYWORDS: Disclosure; Recovery; Remission; Substance use disorder
BACKGROUND: The meaning of unconscious dreaming has been assigned varying degrees of historical significance throughout the ages and across different cultures including in major psychological theories of psychopathology. While dreams' meaning and implications have remained controversial, not disputed is the occurrence of drinking/drug-using dreams (DDUD) when people enter recovery from a significant alcohol and other drug (AOD) problem. Typically taking the form of a relapse scenario followed by relief on awakening, such dreams can be profoundly unnerving. Beyond common anecdotal reports of these phenomena, however, very little is known about the prevalence, predictors, and decay of such dreams with time in recovery. Greater knowledge could help inform patients and providers about what to anticipate in recovery.
METHOD: Nationally-representative cross-sectional study of US adults (N = 39,093) who had resolved a significant AOD problem (weighted n = 2002).
MEASURES: DDUD prevalence/time since last DDUD; demographics; measures of clinical history.
RESULTS: Approximately one third (31.9%) reported experiencing DDUD which were predicted by more severe clinical history variables (earlier age of onset; prior treatment/mutual-help participation). A significant linear decay of DDUD occurrence was observed with time in recovery.
CONCLUSIONS: DDUD appear to occur among a substantial minority of US adults resolving significant AOD problems and are related to a more pronounced and deleterious AOD history. DDUD attenuate in frequency over time in recovery which plausibly may be indicative of increased biopsychosocial stability that reduces neurocognitive reverberation and psychological angst regarding relapse risk. Further prospective research is needed to understand the frequency, topography, content variability, and influence such dreams may have on intermediate (e.g., abstinence self-efficacy) and ultimate (substance use) outcomes.
Problematic substance use is a challenge worldwide among adolescents. The recovery process requires holistic support addressing multiple and intersecting substance use risk factors; yet, there remains a lack of evidence on how to best understand and support adolescents in recovery. Recovery capital (RC) is a model that can be used to identify areas of assets that could be enhanced and barriers to address in one’s recovery process; however, this construct was generated through a study of adults who achieved natural recovery and it has since been used to frame adult recovery-related literature across the world. The primary aim of this article is to outline the rationale for and present a Recovery Capital for Adolescents Model (RCAM). The article will discuss the original recovery capital model, describe adolescent development, substance use, and recovery, and detail proposed developmental adaptations. Future qualitative and quantitative research should explore the RCAM to assess whether the proposed dimensions are complete as well as to assess its utility in clinical settings for identifying strengths and barriers for adolescents in or seeking recovery.
When the President's Commission on Combating the Opioid Crisis declares “addiction [a] chronic relapsing disease of the brain”1 and calls for expanded access to care, within those statements is recognition of the influx of patients with addiction into general medicine settings for chronic disease management. The initial conversations that can shape a patient's understanding of addiction will occur more and more within primary care offices or at the bedside in the general medicine wards. The stakes are high: how patients understand their addiction may shape their health behaviors, relationship with their care team, and willingness to accept treatment.
A major emphasis in addiction treatment is to implement interventions that improve patients' outcomes and quality of life. Despite this worthy goal, the field has been beset by numerous challenges: immense variation in the uptake and implementation of evidence-based practices; large variability in quality care—even when evidence-based practices are adopted; and inadequate demonstration of improved patient outcomes when programs actually do deliver evidence-based practices with high fidelity. Together with the overselling of addiction treatment effectiveness by some sectors of the treatment field, these observations have led to calls for much greater accountability, including a move toward systematic measuring and reporting of patients' treatment outcomes or measurement-based practice (MBP). This chapter describes the rationale and preliminary evidence for MBP and discusses the clinical and public health implications for its widespread adoption and implementation across the addiction treatment field.
Relational processes (i.e., disclosure, stigma, social support) experienced by youth with substance use disorders (SUDs) and their caregivers may act as barriers to, or facilitators of, recovery but are understudied. Single-session qualitative semi-structured interviews were conducted with 19 patients and 15 caregivers recruited by clinicians from a SUD program. There was variability in disclosure experiences, including how many people knew about patients’ SUD diagnosis and treatment, whether patients or caregivers primarily disclosed to others, and feelings about others knowing about one’s or one’s child’s SUD treatment. After disclosing, patients and caregivers experienced stigmatizing (e.g., social rejection) and supportive (e.g., understanding, advice) reactions from others. Disclosures may have important implications for relationship and recovery-related outcomes. Moreover, some child-caregiver pairs have significant disagreements regarding disclosure of SUD treatment. Addressing relational processes within treatment by encouraging patients and caregivers to share the disclosure decision-making process may support the recovery of youth with SUDs.
Kelly, J. F., Bergman, B. G., & O'Connor, C. M. (2018). Evidence-based Treatment of Addictive Disorders: An Overview. In J. W. MacKillop, G. A. Kenna, L. Leggio, & L. A. Ray (Ed.), Integrating Psychological and Pharmacological Treatments for Addictive Disorders: An Evidence-Based Guide . Routledge Press.
Empirical evidence indicates that, in general, treatments which systematically engage adults with freely available twelve-step mutual-help organizations (TSMHOs), such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) often enhance treatment outcomes while reducing health care costs. Also evident is that TSMHOs facilitate recovery through mechanisms similar to those mobilized by professional interventions, such as increased abstinence self-efficacy and motivation, as well changing social networks. Much less is known, however, regarding the utility of these resources specifically for young adults and whether the TSMHO mechanisms are similar or different for young adults. This article provides a narrative review of the clinical and public health utility of TSMHOs for young adults, and summarizes theory and empirical research regarding how young adults benefit from TSMHOs.
Results indicate that, compared to older adults, young adults are less likely to attend TSMHOs and attend less frequently, but derive similar benefit. The mechanisms, however, by which TSMHOs help, differ in nature and magnitude. Also, young adults appear to derive greater benefit initially from meetings attended by similar aged peers, but this benefit diminishes over time.
Findings offer developmentally specific insights into TSMHO dynamics for young adults and inform knowledge of broader recovery needs and challenges.
A body of literature has shown that free, widely available mutual-help organizations (MHOs), such as Alcoholics Anonymous (AA), offer cost-efficient community-based sources of recovery support for individuals with substance use disorder (SUD). Emerging adults (18–29 years old) are a prevalent group of individuals in the SUD treatment system who present unique challenges and typically have poorer outcomes than those of older adults (e.g., 30+ years). Given the need to identify low-cost strategies that can help destabilize the course of SUD for emerging adults, this chapter reviews the extent to which emerging adults participate in MHOs and the degree to which they benefit from participation in MHOs. The chapter also outlines the mechanisms through which MHO participation promotes better outcomes and the factors that influence emerging adults’ MHO participation and participation-related benefit. The chapter then highlights opportunities for timely but as-of-yet untapped targets for emerging adult recovery-related research, such as the intersection between MHO participation and opioid agonist treatment.