12-step Program Participation Research Articles

Levels and outcomes of 12-step participation among sexual and gender minority subgroups

IntroductionSexual minority (e.g., bisexual, gay, lesbian, queer) and gender minority (e.g., transgender, non-binary, gender expansive) individuals (SGMI) experience higher rates of alcohol and other substance use disorders than their heterosexual and cisgender (i.e., non-transgender) counterparts. 12-Step programs are currently the most common source of support for alcohol and other substance use-related problems in the United States. Little is known about rates and levels of participation and outcomes of SGMI in 12-Step programs. Examining SGMI with a lifetime alcohol or other substance use disorder, this study aims to: 1) describe lifetime attendance rates (any vs. none) and levels of participation (number of program activities) in 12-Step groups among SGMI overall and compare rates of attendance and levels of participation across sexual and gender minority identities and 2) determine how lifetime level of participation in 12-Step programs relates to past-year alcohol and other substance use outcomes. MethodsWe used data collected through The PRIDE Study, a national, large-scale, longitudinal health study of adult SGMI, administering supplemental questions to assess alcohol and other substance use disorders and 12-step participation. Zero-Inflated Negative Binomial models (N = 1353) run with sexual and gender identities as predictors of lifetime 12-step attendance (yes/no) and level of 12-Step participation determine if greater levels of 12-Step participation were associated with lower levels of past-year Alcohol and Substance Use Disorder (AUD & SUD) symptoms. The study ran models for those with lifetime AUD (n = 1074) and SUD (n = 659) separately. ResultsParticipants who engaged in greater levels of 12-Step participation had lower levels of past-year AUD and SUD symptoms. Gay and queer respondents with AUD were more likely and lesbian respondents with SUD were less likely than other participants to have ever participated in 12-Step programs. All other associations between sexual/gender identities and 12-Step participation disappeared when age was added to the model. ConclusionsThis study provides preliminary evidence that 12-Step participation may be an effective resource for reducing AUD and SUD symptoms among SGMI. Younger SGMI and SGMI holding sexual/gender identities other than gay and queer may require additional support to initiate participation in 12-Step programs.

Participation in 12-Step Programs and Drug Use Among Older Adults With Cannabis Use Disorder: Six-Month Outcomes

This study examined associations among cannabis use disorder (CUD), 12-step program participation, and cannabis and other drug use at baseline and 3- and 6-month follow-ups. Participants were age 50 or older in a study of veterans receiving medical management of alcohol and/or opioid withdrawal ( N = 171). Generalized estimating equations examined the extent to which time point, 12-step program participation, and CUD were associated with change in number of cannabis and non-cannabis drug use days. Also examined was whether having CUD was associated with 12-step program participation. From baseline through the 6-month follow-up, 12-step program participation increased, non-cannabis drug use decreased, and cannabis use remained stable. Twelve-step program participation at baseline was associated with better outcomes at follow-ups. Participants with CUD reported less 12-step program participation and more cannabis use days at follow-ups. Older adults with CUD may need other types of psychosocial treatments due to low participation in 12-step programs.

The Twelve Steps and Adolescent Recovery: A Concise Review.

Recovery and long-term remission are the goals of treatment for substance use disorders, yet the majority of treated adolescents never stop using or resume using substances quickly after treatment. Thus, continuing care or recovery support services are common post-treatment recommendations for this group. Almost half of people who resolved significant substance use problems did so through participation in 12-step programs like Alcoholics Anonymous or Narcotics Anonymous. These recovery support programs are available online and in communities around the world. Yet <2% of these programs’ members are under 21 years old. To help clinicians understand the 12-step explanatory model and facilitate clinical decision making on whether or when to refer individuals to these groups, this article summarizes the 12-step philosophy and practices and provides a concise review of research on adolescents’ involvement in 12-step groups, including qualitative work that illuminates adolescents’ reasons for resisting or engaging in 12-step practices.

Drug use among HIV+ adults aged 50 and older: findings from the GOLD II study

ABSTRACTUnderstanding the nexus of aging, HIV, and substance use is key to providing appropriate services and support for their aging, HIV seropositive patients. The proportion of PLWHA aged 50 and older is growing due to a variety of factors like decreases in mortality due to highly active retroviral therapy and non-negligible HIV incidence. We describe prevalence of alcohol, tobacco, and other drug use and participation in substance use treatment and 12-step programs among 95 HIV-positive patients aged 50 and older engaged in care. Most (73.7%) smoked cigarettes in their lifetime and 46.3% were current smokers. Most were at medium (81.1%) or high risk (13.7%) for an alcohol use disorder. With respect to illicit drug use, 48.4% had used marijuana, cocaine, crack, methamphetamines, heroin, and/or prescription opiates without a prescription in the last 12 months; 23.2% met criteria for drug dependence. Marijuana was the most commonly reported illicit drug (32.6%) followed by cocaine and crack (10.5% each), heroin and prescription opiates (7.4% each), and methamphetamines (6.3%). Among those who had not used drugs in the past 12 months, 36.7% had been in a substance use treatment program and 26.5% had participated in a 12-step program in their lifetime; 8.2% were currently in treatment and 16.3% were currently participating in a 12-step program. Among those who had used an illicit drug in the past 12 months, 37.0% had never been in treatment, 34.8% had been in treatment in their lifetime, and 28.3% were currently in treatment. With respect to 12-step programs, 27.3% of those meeting dependence criteria had never participated, 45.5% had participated in their lifetimes, and 27.3% were currently participating. Our findings suggest that older adults in HIV care settings could benefit from Screening, Brief Intervention, and Referral to Treatment interventions and/or integrated services for substance abuse and medical treatment.

Enhancing the Referral-Making Process to 12-Step Programs

Objectives: This study examines three preparatory strategies that can be used during treatment sessions to bridge the gap between clinician recommendations for client participation in 12-step programs (TSPs) and client adherence to such recommendations. Methods: A sample of 284 clinicians completed an online survey. Clinicians responded to items measuring their willingness to motivate client participation in TSPs, integrate 12-step principles into sessions, and form positive attitudes toward 12-step culture. Analysis was conducted using structural equation modeling (SEM). Results: Clinician attitudes toward 12-step culture had a significant effect on clinician willingness to motivate client participation in TSPs. Clinician attitudes toward 12-step culture also mediated the effect of integrating 12-step principles into treatment sessions on willingness to motivate client participation in TSPs. Conclusions: Because positive attitudes toward 12-step culture play a central role in the referral-making process, it is recommended that clinicians cultivate positive attitudes toward 12-step culture.

12-step facilitation for the dually diagnosed: A randomized clinical trial

There are few clinical trials of 12-step treatments for individuals with serious mental illness and alcohol or drug dependence. This randomized trial assessed the effects of adding a 12-session 12-step facilitation therapy (TSF), adapted from that used in Project MATCH, to treatment as usual in an outpatient dual diagnosis program. Participants were 121 individuals dually diagnosed with alcohol dependence and a serious mental disorder, followed during 12 weeks of treatment and 36 weeks post-treatment. Participants receiving TSF had greater participation in 12-step programs, but did not demonstrate greater improvement in alcohol and drug use. However, considered dimensionally, greater participation in TSF was associated with greater improvement in substance use, and greater 12-step participation predicted decreases in frequency and intensity of drinking. Findings suggest that future work with TSF in this population should focus on maximizing exposure to TSF, and maximizing the effect of TSF on 12-step participation.

Current cigarette smoking among HIV-positive current and former drug users: associations with individual and social characteristics.

Cigarette smoking is endemic among HIV-positive populations and is related to substantial morbidity and mortality. Research has largely focused on individual-level characteristics associated with smoking, with less attention to social factors. We aimed to explore individual- and social-level characteristics associated with current cigarette smoking among people living with HIV. Data came from 358 individuals on antiretroviral therapy interviewed in a study on informal HIV caregiving, conducted in Baltimore, MD, USA. Most participants (75 %) were current smokers and 45 % reported current illegal drug use. In adjusted logistic regression analyses, current drug use (aOR 2.90, 95 % CI 1.58-5.30), 12-step program participation (aOR 1.74, 95 % CI 1.02-2.97), and having a main Supporter who is a current smoker (aOR 1.93, 95 % CI 1.12-3.33) were associated with current smoking. Findings suggest the importance of social-level factors in cigarette smoking among HIV seropositive drug users and have implications for developing targeted smoking cessation interventions for smokers living with HIV.

Twelve-step program attendance and polysubstance use: interplay of alcohol and illicit drug use.

The primary aim of this study was to advance understanding of the efficacy of 12-step programs by determining the temporal relationships between alcohol and illicit drug use among 12- step program affiliates. A total of 253 early 12-step affiliates without extensive histories of Alcoholics Anonymous (AA) attendance were recruited from substance use treatment and community-based AA. A majority of the sample met criteria for a diagnosis of alcohol dependence, reported lifetime use of illicit drugs, and reported illicit drug use in the 90-day period before recruitment. After informed consent, participants were interviewed at intake and in 3-month increments for 1 year. Preliminary analyses indicated that 12-step attendance was predictive of reductions in substance use and that such reductions were not moderated by illicit substance use disorder diagnosis or alcohol problem severity. Lagged hierarchical linear models indicated that illicit drug use was a robust predictor of later use of alcohol, although the frequency and intensity of drinking were contingent on whether participants sustained 12-step program affiliation. Alcohol use did not predict later illicit drug use among participants who sustained 12-step program participation. Findings suggest that 12-step participation may serve as a protective factor after substance use occurs. Although our results suggest that the initiation of illicit drug use may undermine efforts to achieve and sustain abstinence from alcohol, our findings do not suggest that alcohol use necessarily mobilizes relapse across different substances among 12-step program affiliates.

Correlates of participation in peer recovery support groups as well as voluntary and mandated substance abuse treatment among rural and urban probationers

This study explores the correlates of probationers' participation in 12-step programs, voluntary treatment, and mandated treatment, with respect to the geographic location of where the services are being provided as the primary covariate of interest. Data were derived from face-to-face interviews with rural and urban probationers ( N = 1,464). Results of the three logistic regression models suggested that even when all the covariates are taken into account, urban probationers were significantly more likely to have been involved in 12-step programs, voluntary treatment, and mandated treatment over their lifespan. Despite high levels of self-reported substance use among all participants, treatment services were underused by rural probationers. These data suggest that individuals residing in rural communities may face additional barriers to receiving treatment services and that criminal involvement is associated with participation in peer recovery support groups and treatment. Future studies can investigate criminal involvement as an avenue to enhance recovery and how to overcome treatment barriers in rural areas.

Changes in Religious Coping and Relapse to Drug Use Among Opioid-Dependent Patients Following Inpatient Detoxification

Relapse rates remain high among people with opioid dependence. Identifying psychosocial factors associated with outcomes is important for informing behavioral treatments. This study examined religious coping, opioid use, and 12-step participation among 45 participants receiving inpatient opioid detoxification at baseline and follow-up. At baseline, higher positive coping was related to less frequent opioid use pre-admission (β = -.44, p < .001) and history of 12-step participation (OR = 2.33, p < .05). Decreases in negative coping after discharge predicted less opioid use (β = .55, p < .001), and increases in positive coping predicted more frequent 12-step program participation (β = .42, p < .05). Positive religious coping may be protective, while negative religious coping may be a barrier to treatment.

Vigilance and the Drug-dependent Anesthesiologist

Physician Health Committee of the Medical Society of the District of Columbia and Georgetown University Law Center, Washington, DC. ccohenp@aol.comThe recent editorial by Berge and colleagues1sends an extremely important message to the anesthesia community, and I agree with many of its thoughtful and incisive points. However, I must take issue with the authors’ proposed new default position of “one strike, you’re out.” I believe that the question of return to work is far too complex to be approached in a monolithic fashion that lumps all anesthesiologists who have manifested drug dependence into a single group that “should be directed toward lower-risk occupational environments, either within medicine or in a different field entirely.”A uniform prognosis cannot be assigned to every drug-dependent anesthesiologist. For example, Domino et al. 2suggest that dual diagnosis and family history are among the major factors that must be taken into account when predicting the risk of relapse in opioid-addicted physicians. My own experience supports an additional and extremely important variable that must be considered when deciding whether or not a drug-dependent anesthesiologist should return to his or her profession: The availability of long-term supervision, support, and monitoring. The Medical Society of the District of Columbia’s Physician Health Committee (PHC) intervenes on physicians whose colleagues (and sometimes themselves) believe them to be suffering from the disease of drug dependence. The PHC refers this physician to a specialist in addiction medicine and, if recommended, facilitates admission to treatment (usually residential). Immediately after discharge the physician, now in early recovery, enters into a five-year contract with the PHC. This contract mandates random drug testing (a daily phone call determines whether or not an observed urine sample must be furnished within the next 12 h), monitoring by a member of the PHC, participation in 12-step programs, and continuing aftercare under the supervision of an addictionologist. Some of our clients also submit hair samples for drug testing every two to three months. Our recommendation for a graduated return to work is made only after we receive a recommendation from the treating specialist that this would be appropriate. Aftercare of opioid-addicted anesthesiologists in recovery may include the use of depot naltrexone. At least one supervisory member of the department is made aware of the individual’s history at the time of return and is informed that the PHC will be responsible for monitoring.Approximately 90% of physicians (including anesthesiologists) enrolled in the Washington, DC Medical Society’s Physician Health Program have successfully completed their 5-yr contracts.3The PHC has monitored sufficient numbers of anesthesiologists in recovery whose return to work has been recommended to support my stance that “one strike” need not preclude reentry into anesthesiology. At the present time, although some of our clients do indeed voluntarily leave anesthesiology for another medical specialty, those who have returned to the practice of anesthesiology have been successful in their recovery. While the group of anesthesiologists with whom we have experience is small in comparison with the entire national cohort, our observations support my view that individual consideration, long-term close surveillance, and aftercare by specialists in addiction medicine may provide an alternative to the editorial’s default position.In contrast, the editorial1appears to base at least some of its argument on a “pragmatic review of our personal experience with our Mayo Clinic nurse anesthetists,” leading to the observation that “there has been nearly a 100% relapse rate” (relapse is not defined and could represent anything from a single “slip” to a full-fledged resumption of frequent drug use). It is significant that the authors do not provide evidence of long-term monitoring of these nurse anesthetists. Indeed, they state that “it is difficult to exactly quantify the relapse rate, because far too often affected individuals are simply lost to formal follow-up.”Finally, the editorial refers to Gastfriend’s statement that addiction is “a brain disease that subverts self-preservation”4to support its contention that “decision-making is damaged by addiction so that abstinence is not simply a choice.” However, Gastfriend also clearly emphasizes—quoting reports from several other Physician Health Programs—that “the vast majority of physicians who have substance use disorders seem to do surprisingly well in recovery.” While I certainly do not disregard the unmistakable threat that addiction poses to anesthesiologists and patients, my own personal experience, and that of other PHC chairs, suggests that the editorial’s pessimism is not justified. Documented sobriety is possible within the operating room environment. When complemented with vigilance,*including supportive and careful long-term monitoring, return to work can be successful for both the physician and society.Physician Health Committee of the Medical Society of the District of Columbia and Georgetown University Law Center, Washington, DC. ccohenp@aol.com

Identifying Client-Level Indicators of Recovery Among DUI, Criminal Justice, and Non–Criminal Justice Treatment Referrals

This study is part of a mandated treatment outcome study on all government-funded programs in a rural state. This naturalistic study included a sample of 888 clients who served between July 2003 and June 2004 in a state-funded treatment for substance misuse and were included in a follow-up interview 12 months after treatment. To examine differences in treatment outcome, clients were examined in three referral conditions: (1) driving under the influence (DUI) referral; (2) criminal justice referral; and (3) non–criminal justice referral. While more DUI referrals reported alcohol use at 12-month follow-up, there were no other differences between referral conditions. Instead, controlling for factors like age, gender, and race, recovery intent at intake, and 12-step program participation at follow-up predicted positive treatment outcomes, while persistent depression predicted negative outcomes. This study of clients in state-funded treatment for substance misuse provides additional evidence that referral condition does not predispose clients toward positive or negative outcomes. Secondly, client-level factors related to recovery practices and intent to reduce or stop using substances may need closer attention in the clinical process. Study limitations included data being collected by clinicians during intake, which may have resulted in reliability questions about how data are entered.

Twelve-Step Subculture and Cultural Competency Among Clinicians

In their insightful article, Holleran and MacMaster make two insightful propositions about 12-step programs. First, they propose that a distinct subculture exists in these programs. Second, they propose that clinicians need to understand this subculture to work effectively with 12-step program participants. Empirical evaluations of these propositions can contribute to theory development and illuminate effects of 12-step program participation on recovery and well-being

Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder

We conducted a randomized controlled trial to evaluate whether dialectical behavior therapy (DBT), a treatment that synthesizes behavioral change with radical acceptance strategies, would be more effective for heroin-dependent women with borderline personality disorder ( N=23) than Comprehensive Validation Therapy with 12-Step (CVT+12S), a manualized approach that provided the major acceptance-based strategies used in DBT in combination with participation in 12-Step programs. In addition to psychosocial treatment, subjects also received concurrent opiate agonist therapy with adequate doses of LAAM (thrice weekly; modal dose 90/90/130 mg). Treatment lasted for 12 months. Drug use outcomes were measured via thrice-weekly urinalyses and self-report. Three major findings emerged. First, results of urinalyses indicated that both treatment conditions were effective in reducing opiate use relative to baseline. At 16 months post-randomization (4 months post-treatment), all participants had a low proportion of opiate-positive urinalyses (27% in DBT; 33% in CVT+12S). With regard to between-condition differences, participants assigned to DBT maintained reductions in mean opiate use through 12 months of active treatment while those assigned to CVT+12S significantly increased opiate use during the last 4 months of treatment. Second, CVT+12S retained all 12 participants for the entire year of treatment, compared to a 64% retention rate in DBT. Third, at both post-treatment and at the 16-month follow-up assessment, subjects in both treatment conditions showed significant overall reductions in level of psychopathology relative to baseline. A noteworthy secondary finding was that DBT participants were significantly more accurate in their self-report of opiate use than were those assigned to CVT+12S.

12-Step Program Participation and Effectiveness: Do Gender and Ethnic Differences Exist?

Although 12-Step is increasingly utilized as a recovery resource and is viewed by many addiction specialists as an integral component of treatment and long-term recovery, questions regarding participation and effectiveness of 12-Step programs for women and ethnic minorities have been raised. Utilizing data from the Los Angeles Target Cites Evaluation Project (n = 356), participants in adult outpatient alcohol and drug treatment were followed for 24 months and rates of 12-Step participation and effectiveness were assessed for all gender and ethnic groups. Contrary to reports that 12-Step is more appropriate for European-American males, statistical analyses reveals that women and ethnic minorities are equally likely to attend 12-Step programs, and to recover In conjunction with such participation as European-American males. Although 12-Step may not appeal to all seeking to cease alcohol and drug use, the clinical implications for treatment providers and other addiction specialists points to the benefits of Integrating 12-Step components into traditional treatment programs and recommending 12-Step participation for clients of all gender and ethnic groups.

12-Step Participation and Attitudes Toward 12-Step Meetings in Dual Diagnosis Patients

This study examined participation in 12-step programs and attitudes toward 12-step meetings in an outpatient sample of 81 severely mentally ill patients with comorbid substance use disorders. The study found that dual diagnosis patients attended 12-step programs at rates comparable to those reported for patients in primary addiction treatment settings. Diagnosis and attitudes toward 12-step meetings each had independent effects on 12-step participation. The difficulties that some dual diagnosis patients report experiencing at 12-step meetings may need to be addressed to maximize 12-step attendance and potential to benefit from 12-step programs.

Drug treatment and 12-step program participation: the additive effects of integrated recovery activities.

The dramatic rise in the number of 12-step programs and participants raises questions concerning client participation in drug treatment and 12-step programs, and their separate and combined effects on recovery. The results of a treatment outcomes study indicate that rather than recovery alternatives, drug treatment and 12-step programs are utilized by the client as integrated recovery activities. Treatment participants with pretreatment 12-step involvement stayed in treatment longer, and were more likely to complete the 24-week program. Both pretreatment 12-step involvement and duration of participation in drug treatment are associated with subsequent 12-step involvement. Most importantly, there is an additive effect of these recovery activities in that those who participated concurrently in both drug treatment and 12-step programs had higher rates of abstinence than those who participated only in treatment or in 12-step programs.

Drug Treatment Outcomes: Investigating the Long-Term Effects of Sexual and Physical Abuse Histories

Individuals in drug treatment, particularly women, generally report high levels of past sexual and physical abuse. Although histories of sexual and physical abuse are associated with greater prevalence and severity of depression, anxiety, phobias, and interpersonal difficulties for individuals seeking substance-related treatment, several recent studies failed to show that prior sexual or physical abuse compromised short-term drug treatment outcomes. This study examined the possible effects of sexual and physical abuse on a wide array of behavioral domains over a two-year posttreatment period. The findings indicate few differences bet ween those with and without pasthistories of such abuse in terms of drug use, drug treatment and 12-Step program participation, criminality, income sources, intimatere lationships, family functioning, and psychiatric symptoms. There are specific exceptions, but they apply only to men. Overall, the findings indicate that the impact of sexual and physical abuse histories on relatively long-term treatment outcomes is minimal. Addressing the sexual and physical abuse histories of those seeking treatment for drug abuse may be justified on humanistic grounds, but it will not significantly improve the long-term effectiveness of drug treatment, nor will it substantially enhance the lives of those with histories of abuse.

After Drug Treatment: Are 12-Step Programs Effective in Maintaining Abstinence?

Although participation in 12-step programs is now widely utilized as a treatment aftercare resource by individuals with drug and alcohol problems, little is known about the effectiveness of such a practice. This paper identifies gaps in the existing literature and articulates methodological concerns that may compromise investigations of 12-step programs. It highlights the need for additional after-treatment studies, and it presents findings from a 24-month longitudinal after-treatment study that suggests the effectiveness of 12-step programs. Rather than a behavioral indicator of recovery motivation or a spurious relationship confounded by additional treatment, aftercare, or alumni activities that occur simultaneously with 12-step participation, the findings suggest that weekly or more frequent 12-step participation is associated with drug and alcohol abstinence. Less-than-weekly participation is not associated with favorable drug and alcohol use outcomes, and participation in 12-step programs seems to be equally useful in maintaining abstinence from both illicit drug and alcohol use. These findings point to the wisdom of a general policy that recommends weekly or more frequent participation in a 12-step program as a useful and inexpensive aftercare resource for many clients.

The reliability and validity of interview data obtained from 59 narcotic drug addicts.

The reliability and validity of interview data obtained from 59 narcotic drug addicts.