First Use Of Alcohol Research Articles

Effects of Sibship Size and Composition on Younger Brothers’ and Sisters’ Alcohol Use Initiation: Findings from an Australian Twin Sample

The effects of sibship size and structure on delinquency are well established. Specifically, having a large family and many brothers has been shown to predict offending. However, despite strong links between delinquency and alcohol use, the contribution of sibship factors to drinking behaviors remains largely unexplored. The current study investigated the impact of sibship size and composition on younger brothers' and sisters' ages of drinking and intoxication onset. We employed a sample of 4,281 same-sex twins from the Australian Twin Register to examine whether (i) large sibship size facilitates earlier age at first drink (AFD) and age at first intoxication (AFI) in males and females, (ii) having many older brothers predicts earlier ages of AFD and AFI in males, and (iii) having many older brothers results in later AFD and AFI in females. We tested whether effects were moderated by parental divorce and alcohol misuse and mediated by familial religion. Sibling effects were minimal before accounting for family context. However, when parental divorce and excessive parental drinking were included as moderators, sibling effects were significantly amplified among individuals from homes of divorce, and effects were strongest when siblings were close in age. Strong close in age older sibling effects indicate that proximal sibling attitudes and behaviors about alcohol likely interact with structural factors to influence younger siblings' drinking. Sibship factors were much more influential in one population (individuals from homes of divorce) than another (respondents with a parental history of excessive drinking), suggesting that sibling effects vary depending on the type of co-occurring familial risk. Prevention efforts performed at the family level, and introduced before first use of alcohol, are likely to delay drinking initiation and help prevent future alcohol problems.

Book Review: PDQ (Pretty Darned Quick) Statistics (3rd Edition)

Book by: Geoffrey R. Norman, Ph.D., Professor, Department of Clinical Epidemiology and Biostatistics at McMaster University in Hamilton, Ontario, and David L. Streiner, Ph.D., Assistant Vice President, Research Director of the Kunin-Lunenfeld Applied Research Unit at Baycreat Centre of Geriatric Care, and Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario Review by: Keith D. Anderson, Pharm.D., BCPP, CPNP Publications and Online Products Committee Member

Substance use initiation: The role of simultaneous polysubstance use

Simultaneous polysubstance use (SPU) is a common phenomenon, yet little is known about its role in substance use initiation. In the present study, 226 cannabis users completed structured interviews about their substance use history. For each substance ever used, participants provided details of their age of first use, their use in the preceding 30 days and whether they co-administered any other licit or illicit substances the first time they used the substance. For most illicit substances [powder cocaine, crack, amphetamine, methamphetamine, 3,4-methylenedioxymethamphetamine (MDMA; ecstasy), heroin, opium, gamma-hydroxybutyric acid (GHB), ketamine, psilocybin (magic mushrooms), mescaline, phencyclidine (PCP), peyote and inhalants], results showed that a clear majority of participants (≥75%) reported SPU during their first-ever use of the substance. While SPU was less common on occasions of first use of alcohol, tobacco and cannabis, a high proportion of SPU on occasions of first use of 'harder' drugs could be accounted for by the co-use of alcohol, tobacco and/or cannabis. Such findings raise the possibility that specific alcohol, tobacco and/or cannabis use episodes might directly contribute to the initiation of new substance use. Understanding the role of SPU on occasions of first use might help better identify risk factors for substance use progression and improve intervention efforts.

The association between age at first use of alcohol and alcohol consumption levels among adult general drinking population

Aim The goal of the study was to investigate the association between age at first alcohol use and current levels of alcohol consumption among the adult Australian general drinking population.

Modest Time-Dependent Misclassification in Recalling Age at First Use of Alcohol and Tobacco

To investigate whether recall of age at first use of alcohol and tobacco is time dependent. Respondents aged 14–89 years from the 2001 and 2007 waves of the Australian National Drug Strategy Household Survey were considered as independent samples of the Australian population at two different time points. The means of reported age at first use of alcohol and age at first use of tobacco from the two surveys were compared for each birth cohort. The mean differences were generally small (< 1 year) across birth cohorts. Overall, the increase in mean age at first use from 2001 to 2007 was 0.31 years for alcohol and 0.33 years for tobacco, after controlling for birth cohort and gender effects. The time lag between actual onset of first use and subsequent survey recall can introduce a small systematic bias, but the error is unlikely to pose a threat to retrospective studies that rely on recall information to estimate cumulative exposure of alcohol and tobacco use.

Trends in alcohol use among Israeli high school dropouts, 2004–2009

Background and Aims: Alcohol use is a worldwide problem that has a major impact on public health. The harmful use of alcohol is responsible for more than 4% of the global burden of disease. We investigated alcohol use trends and related problem behaviour among school dropouts from Israel. Methods: We studied 470 school dropouts from 2004 to 2009 based on gender and country-of-origin status. Study participants, with a median age of 17, were referred to a residential facility for drug abuse treatment.Results: Age of first use of alcohol was similar for males and females (median age 13); Former Soviet Union (FSU) youths were significantly younger at the age of first drink; and past 30 day alcohol use reflects no gender or country-of-origin status differences. The majority of dropouts reported binge drinking (51.9%); the level of binge drinking was similar among males and females; however, for the past two study years girls reported significantly more binge drinking than males (60.0%; 40.8%; p < 0.05).Conclusions: Alcohol is the most common substance used among school dropouts; and further research is needed to understand and address the many health and safety concerns of this understudied, high-risk group.

Anxiety as a Predictor of Age at First Use of Substances and Progression to Substance Use Problems Among Boys

This study examined associations of generalized and social anxiety with (1) age at first use of tobacco, alcohol, and marijuana and (2) interval from first use to first problem use of each substance. Participants were 503 males who comprised the youngest cohort (first assessed in the first grade) of the Pittsburgh Youth Study, a longitudinal community-based study of boys. Annual assessments of generalized and social anxiety, delinquency, and substance use from first grade through high school were included. Both types of anxiety predicted earlier first use of alcohol and tobacco, and generalized anxiety predicted earlier first use of marijuana. Both types of anxiety predicted the progression from first use to problems related to marijuana. The effect of generalized anxiety tended to be significant above and beyond the effect of delinquency, while the effect of social anxiety on risk for first use of substances was not. Overall, the associations between anxiety and substance use and related problems depend on the class of substance and the type of anxiety.

Association of parents' alcohol use and family interaction with the initiation of alcohol use by sixth graders: A preliminary study in Taiwan

BackgroundThe family is the main environment where children are socialized and learn individual behavior. Although previous studies have examined predictors of preadolescent first alcohol use, few studies have analyzed factors associated with alcohol use in children in a country with low alcohol consumption. The aim of this study was to investigate the initiation of alcohol use by sixth graders and determine family factors associated with first alcohol use.MethodsData used in this study was collected as part of the Child and Adolescent Behaviors in Long-term Evolution (CABLE) project in 2002 (when study participants were in grade 5 and aged 10–11 years) and 2003 (when study participants were in grade 6 and aged 11–12 years). Data from a total of 1,183 participants was analyzed. Main study variables included children's alcohol use: (1) never user (never user in 2002 and 2003), or (2) first-time user (never user in 2002 but ever user in 2003); parents' alcohol use: (1) both parents ever users, (2) mother ever user and father never user, (3) father ever user and mother never user, (4) both parents never users; parental support; and family conflict. Correlates of first alcohol use were identified using logistic regression.ResultsThere were 183 students (15.5%) who became first-time users of alcohol in the sixth grade. Having parents who both used alcohol, less parental support, and more family conflict were significant predictors of sixth graders' first alcohol use. Family interaction and parents' drinking were equally important predictors of preteen's first use of alcohol.ConclusionFamily factors influence children's initiation of alcohol use. It is important to educate parents about the effects of alcohol on children and to emphasize the importance of prevention.

Common genetic influences on the timing of first use for alcohol, cigarettes, and cannabis in young African-American women

The risks associated with early age at initiation for alcohol, cigarette, and cannabis use are well documented, yet the timing of first use has rarely been studied in genetically informative frameworks, leaving the relative contributions of genetic and environmental factors to age at initiation largely unknown. The current study assessed overlap in heritable and environmental influences on the timing of initiation across these three substances in African-American women, using a sample of 462 female twins (100 monozygotic and 131 dizygotic pairs) from the Missouri Adolescent Female Twin Study. Mean age at the time of interview was 25.1 years. Ages at first use of alcohol, cigarettes, and cannabis were gathered in diagnostic interviews administered over the telephone. Standard genetic analyses were conducted with substance use initiation variables categorized as never, late, and early onset. Variance in the timing of first use was attributable in large part to genetic sources: 44% for alcohol, 62% for cigarettes, and 77% for cannabis. Genetic correlations across substances ranged from 0.25 to 0.70. Shared environmental influences were modest for alcohol (10%) and absent for cigarettes and cannabis. Findings contrast with reports from earlier studies based on primarily Caucasian samples, which have suggested a substantial role for shared environment on substance use initiation when measured as lifetime use. By characterizing onset as timing of first use, we may be tapping a separate construct. Differences in findings may also reflect a distinct etiological pathway for substance use initiation in African-American women that could not be detected in previous studies.

Tipologia de Lesch em alcoolistas no Brasil

OBJETIVOS: Alcoolismo é uma doença heterogênea, com apresentações clínicas, resultados terapêuticos e recaídas variáveis, indicando vulnerabilidades biológicas diferentes. A Tipologia de Lesch distingue quatro categorias de alcoolismo: Tipo I - graves sintomas de abstinência; Tipo II - álcool como solução para conflitos; Tipo III - álcool para "tratamento" de desordens psiquiátricas; Tipo IV - alterações neurológicas antes do uso de álcool. Este estudo verificou a aplicabilidade de uma classificação do tipo clínico de alcoolismo pela Tipologia de Lesch em um ambulatório público brasileiro de atendimento especializado de alta demanda. MÉTODO: Estudo seccional descritivo, que classificou pacientes do ambulatório de alcoolismo do Hospital Universitário da Universidade Federal do Espírito Santo de acordo com a Tipologia de Lesch. RESULTADOS: A diferenciação pela Tipologia de Lesch foi facilmente conduzida em um serviço ambulatorial público de alta demanda. De 170 pacientes, 21,2% foram classificados como Tipo I; 29,4%, Tipo II; 28,8%, Tipo III e 20,6%, Tipo IV. Embora os diferentes tipos de alcoolismo tenham diferentes apresentações clínicas, o padrão de ingestão alcoólica, idade da primeira ingestão e tempo de abstinência não diferiram entre os tipos de alcoolismo. CONCLUSÃO: A distinção do tipo clínico de alcoolismo de acordo com a Tipologia de Lesch foi considerada aplicável em um ambulatório público brasileiro de grande demanda, sendo os dados encontrados semelhantes aos relatados em estudos realizados em diferentes países. A aplicação dessa classificação poderá definir mudanças nas estratégias de enfrentamento individualizadas do alcoolismo, sendo, entretanto, necessários estudos de seguimento para avaliar os resultados terapêuticos das mesmas.

Non-prescribed use of pain relievers among adolescents in the United States

Background We examined gender-specific prevalences, patterns, and correlates of non-prescribed use of pain relievers – mainly opioids – in a representative sample of American adolescents ( N = 18,678). Methods Data were drawn from the public use data file of the 2005 U.S. National Survey on Drug Use and Health, a survey of non-institutionalized American household residents. The patterns of non-prescribed use of prescription pain relievers were examined, and logistic regression procedures were conducted to identify correlates of non-prescribed use. Results Approximately one in 10 adolescents aged 12–17 years reported non-prescribed use of pain relievers in their lifetime (9.3% in males and 10.3% in females). The mean age of first non-prescribed use was 13.3 years, which was similar to the mean age of first use of alcohol and marijuana but older than the age of first inhalant use. Among all non-prescribed users, 52% reported having used hydrocodone products (Vicodin, Lortab, Lorcet, and Lorcet Plus, and hydrocodone), 50% had used propoxyphene (Darvocet or Darvon) or codeine (Tylenol with codeine), and 24% had used oxycodone products (OxyContin, Percocet, Percodan, and Tylox). Approximately one quarter (26%) of all non-prescribed users had never used other non-prescribed or illicit drugs. There were gender variations in correlates of non-prescribed use. Conclusions Use of non-prescribed pain relievers occurs early in adolescence. Research is needed to understand whether early use of non-prescribed pain relievers is related to later drug use.

Evidence of association between early alcohol use and risk of later problems

To investigate the relationship between age of onset, alcohol consumption patterns and related problems. In 2004, one self-administered questionnaire was completed by 1,990 students from the 5th to 11th grades of schools in Paulínia-SP. Data collection was conducted at the classroom without the presence of the teacher. The participation in the study was voluntary and anonymous. Prevalence of lifetime alcohol use was 62.2%. The mean age of first use of alcohol was 12.35 (sd=2.72) and ranged between 5 and 19 years of age. In 78% of the cases, the first use occurred before the age of 15, and more than 22% of the students reported having tried alcohol before 10 years of age. There were significant differences regarding current pattern of use: those who started earlier consumed more drinks per occasion (p=0.013) and had more drunkenness episodes in the last 30 days (p=0.05). A relationship between the age of first alcohol use and the use of tobacco (p=0.017) and other drugs (p=0.047) was observed. Adolescents first use alcohol in early ages, what impacts the current consumption patterns. This study emphasizes the need of actions regarding public alcohol policies in Brazil in order to prevent or delay the initiation of alcohol use and its related problems.

Inhalant Use in Florida Youth

Purpose: To determine (1) the prevalence of use, (2) risk and protective factors for use of inhalants in Florida youth. Methods: The Florida Youth Substance Abuse Survey 2004 is a comprehensive assessment of youth substance abuse attitudes and practices obtained by sampling youth from sixty-five counties. Results: The sample consisted of 60,345 students from 6th to 12th grade; ages 10 to 19 + years (mean 14.5 years ±4), 53% were female with 59% White, 19% African-American, 16% Hispanic, 5% Native American, 2% Asian and 7% other. Lifetime use was highest among 14 year olds (16.5%), and current use among 13 year olds (16.7%). Females had significantly (p < .000) higher rates than males for lifetime (14.2% vs. 12.7%) and current use (5.1% vs. 4.1%). Native Americans had the highest rates of lifetime use (17%) followed by Whites (15%), mixed/other (15%), Hispanics (14%), Asians (13%), and Blacks (9%). The younger the age of first use of alcohol, cigarettes and marijuana, the higher the lifetime and current prevalence of use of inhalants. Inhalant users were more likely to be depressed, acknowledge deviant behavior and skipping school, have lower grades, have siblings and friends who used illegal substances and parents with a history of antisocial behavior (p < .000). Conclusion: Inhalant use may be a marker for adolescents with a high-risk profile for subsequent illegal drug use. Prevention efforts should be directed to these students at an early age.

Postdischarge Cannabis Use and Its Relationship to Cocaine, Alcohol, and Heroin Use: A Prospective Study

Research on the effects of cannabis on the brain and behavior has been surprisingly scarce. In humans, laboratory studies document toxicity and psychoactive effects of cannabinoids. However, among substance abuse patients, only a few studies have prospectively examined the relationship of cannabis use to remission or relapse of use of other substances. Because cannabis is a widely used substance, the authors examined whether cannabis use during follow-up after discharge from inpatient treatment affected cocaine, alcohol, and/or heroin use. Two hundred fifty patients 18 years old or older from an inpatient psychiatric/substance abuse setting participated in a Psychiatric Research Interview for Substance and Mental Disorders. All patients were diagnosed according to DSM-IV as having current alcohol, cocaine, and/or heroin dependence. Sustained remission was defined as at least 26 weeks without use following hospital discharge. Data were analyzed with Cox proportional hazards models. About one-third of the patients (N=73) used cannabis after hospital discharge. Postdischarge cannabis use substantially and significantly increased the hazard of first use of any substance and strongly reduced the likelihood of stable remission from use of any substance. Examination of specific substances indicated that cannabis use affected first use of alcohol, stable remission, and subsequent relapse of alcohol use as well as first use of cocaine and stable remission but was unrelated to heroin outcomes. Potential negative clinical implications of cannabis use should be considered when treating dependence on other substances and planning aftercare. Clinical and laboratory research is needed to provide understanding of the mechanisms of cannabinoids in relapse to alcohol and cocaine use.

Association of Antisocial Personality Disorder and Substance Disorder Morbidity in a Clinical Sample

Objectives: The aims were to determine among patients with substance use disorder (SUD) whether those with antisocial personality disorder (ASPD) manifest less, the same, or more of the following: 1) temporal course of substance use, 2) severity of substance-related symptoms and problems, 3) familial SUD, 4) number and type of SUD diagnoses, and 5) extent of SUD treatment, as compared to patients without ASPD. Design and Definition: Scheduled interviews using Diagnostic and Statistical Manual (DSM) criteria were used to determine ASPD, which required childhood conduct disorder plus adult antisocial behavior. Clinicians blind to the ASPD assessment collected the remainder of the data. Settings: Alcohol-drug treatment programs were located in two university medical centers. Subjects: Six hundred and six voluntary patients aged 18 and older met diagnostic criteria for SUD. Results: SUD patients with ASPD reported more substance-related problems in seven out of eight areas of the interview-based Minnesota-Substance Abuse Problems scale. On a self-rated scale, the Michigan Assessment Screening Test/Alcohol-Drug, the difference was unremarkable. The ASPD group reported slightly, but significantly, more relatives with SUD. Lifetime use of tobacco and most illicit drugs was greater in the ASPD group. Age at first use of alcohol and tobacco was less in the ASPD group, but age at first use of other substances did not show a difference. Indicators of SUD course, such as years of use, days of use in the last year, duration of periods of abstinence, and number of self-help efforts showed no differences between the two groups. Types and numbers of SUD diagnoses showed no difference. However, all treatment indicators (i.e., lifetime number of admissions, modalities of care, days of care, and cost of care) were significantly higher in the ASPD group. A regressionanalysis revealed that family and legal problems remained strongly associated with ASPD, but other substance-related problems and SUD treatment dropped out. Conclusions: Despite the many similarities in SUD among those with and without ASPD, the morbidity in the ASPD as measured by number and types of substance-related problems and by all treatment variables is considerably greater. Legal and family problems appear to be powerfully associated with ASPD and predictive of other problems as well as SUD treatment.

Association of Antisocial Personality Disorder and Substance Disorder Morbidity in a Clinical Sample

The aims were to determine among patients with substance use disorder (SUD) whether those with antisocial personality disorder (ASPD) manifest less, the same, or more of the following: 1) temporal course of substance use, 2) severity of substance-related symptoms and problems, 3) familial SUD, 4) number and type of SUD diagnoses, and 5) extent of SUD treatment, as compared to patients without ASPD. DESIGN AND DEFINITION: Scheduled interviews using Diagnostic and Statistical Manual (DSM) criteria were used to determine ASPD, which required childhood conduct disorder plus adult antisocial behavior. Clinicians blind to the ASPD assessment collected the remainder of the data. Alcohol-drug treatment programs were located in two university medical centers. Six hundred and six voluntary patients aged 18 and older met diagnostic criteria for SUD. SUD patients with ASPD reported more substance-related problems in seven out of eight areas of the interview-based Minnesota-Substance Abuse Problems scale. On a self-rated scale, the Michigan Assessment Screening Test/Alcohol-Drug, the difference was unremarkable. The ASPD group reported slightly, but significantly, more relatives with SUD. Lifetime use of tobacco and most illicit drugs was greater in the ASPD group. Age at first use of alcohol and tobacco was less in the ASPD group, but age at first use of other substances did not show a difference. Indicators of SUD course, such as years of use, days of use in the last year, duration of periods of abstinence, and number of self-help efforts showed no differences between the two groups. Types and numbers of SUD diagnoses showed no difference. However, all treatment indicators (i.e., lifetime number of admissions, modalities of care, days of care, and cost of care) were significantly higher in the ASPD group. A regression analysis revealed that family and legal problems remained strongly associated with ASPD, but other substance-related problems and SUD treatment dropped out. Despite the many similarities in SUD among those with and without ASPD, the morbidity in the ASPD as measured by number and types of substance-related problems and by all treatment variables is considerably greater. Legal and family problems appear to be powerfully associated with ASPD and predictive of other problems as well as SUD treatment.

Onset of alcohol and tobacco use and transition to other drug use among students from Morelos, Mexico

To estimate the cumulative probability of occurrence of first use of alcohol and tobacco, and the risk of transition to illegal drugs (marijuana, cocaine, and heroine, among others), in adolescents and young adults, in Morelos State, Mexico. A cross-sectional study was conducted during schoolyear 1998-1999, among 13 293 students aged 11-24 years, selected from public schools by probabilistic multistage sampling. Data were collected on sociodemographic, health status, and substance abuse variables, using a validated self-applied questionnaire. Data were restructured to assemble a synthetic cohort for discrete time survival analysis. Associations were assessed with hazard rates and 95% confidence intervals obtained by means of multivariate Cox regression models. Sixty percent of males started drinking alcohol at 17 years of age, and smoking tobacco at 18 years of age, on average. Women started using alcohol and tobacco one year after men. Utilization of illicit drugs occurred at 19 years of age on average in 5% of women and 13% of men. Nine out of every 100 illicit drug users started directly using illicit drugs without previous use of alcohol and/or tobacco. In general, alcohol or tobacco users were at greater risk of starting drug use than nonusers (RR=6.72; 95 % confidence interval [CI]=4.13-10.93). Study findings suggest that interventions to decrease drug abuse should go together with efforts to delay initiation of alcohol and tobacco use. The innovative method used in this study yields epidemiologic evidence relating early use of alcohol and tobacco with initiation of illegal drugs in Mexican students.

Alcohol, Tobacco, Other Drug Use, and Violent Behavior Among Native Hawaiians: Ethnic Pride and Resilience

The present study includes data from a sample of 88 Native Hawaiians living in a rural community on an outer island. Alcohol, tobacco, and other drug (ATOD) use, and violent behavior were examined, including age at first experience, lifetime and 30-day frequency of experience, and interference related to substance use, along with other resilience indicators such as self-reported health, happiness, and ethnic identity. The data suggested that age at first use of alcohol, tobacco, and other drugs appeared to occur within the same period of time, at approximately age 16. With respect to violent behavior, educational attainment was higher for individuals whose age at first victimization was later. Two relationships were found between ATOD use and violent behavior. First, the data suggest that the age at first use of alcohol was significantly correlated with lifetime frequency of violence exposure including witnessing, perpetrating, and being a victim of violence. Second, age at first victimization was correlated with current marijuana use, while age at first perpetration of violence was correlated with current crystal methamphetamine use. Lastly, individuals reporting very strong ethnic pride had significantly fewer lifetime instances of witnessing, perpetrating, and being the victim of violence. Thirty-day frequencies of perpetrating and being the victim of violence were also significantly different between respondents who reported very strong ethnic pride and those who reported being less proud, suggesting that ethnic pride is an important protective factor against experiencing violent behavior and may encourage resilience in this group.

Developmental sequence from disruptive behavior diagnosis to adolescent alcohol dependence.

The authors sought to clinically describe the relationship of disruptive behavior disorders with both alcohol dependence and the use of a variety of substances. The Child Semi-Structured Assessment for the Genetics of Alcoholism was used to collect data on 54 adolescents with a diagnosis of alcohol dependence. The frequency and age at onset of the disruptive behavior disorder diagnoses were examined as well as age at first use of alcohol, tobacco, marijuana, and other street drugs. Nearly three-quarters of the alcohol-dependent adolescents had at least one disruptive behavior disorder diagnosis. Attention deficit hyperactivity disorder (ADHD) typically occurred first, followed by conduct disorder. Substance use began with alcohol or tobacco, followed by marijuana and then other street drugs. Alcohol dependence began significantly later than the onset of either ADHD or conduct disorder and significantly later than the first use of tobacco. Disruptive behavior diagnoses, particularly conduct disorder, typically precede the initiation of use of a variety of substances that, in turn, precede the diagnosis of alcohol dependence in adolescents.

FACTORS ASSOCIATED WITH FREQUENCY OF 12-STEP ATTENDANCE BY DRUG ABUSE CLIENTS

Comparison was made of treatment clients attending Narcotics Anonymous and/or Alcoholics Anonymous meetings less than weekly (n = 41) with treatment clients attending meetings at least three times a week (n = 30). The frequent attenders (attending an average of 30.6 meetings monthly) differed from non- and infrequent attenders (attending an average of 0.4 meetings monthly) in terms of histories of greater lifetime drug use, more arrests and treatment experiences, and an earlier age of first use of alcohol. Although the frequent attender was also older, age was not found to influence the differences found between groups. Measures of religiosity, use of community services, and support from others for recovery and psychological functioning, other than ratings of the helpfulness of 12-Step, were not differentiated among groups. The findings suggest that 12-Step groups are more likely to be selected by clients with more severe histories of drug use and criminal activity, i.e., those most in need of the support to behavior change those groups provide. The role of treatment programs in facilitating the use of 12-Step groups is discussed.