Lee Ann Kaskutas

Self-help organizations for alcohol and drug problems: Toward evidence-based practice and policy

This expert consensus statement reviews evidence on the effectiveness of drug and alcohol self-help groups and presents potential implications for clinicians, treatment program managers and policymakers. Because longitudinal studies associate self-help group involvement with reduced substance use, improved psychosocial functioning, and lessened health care costs, there are humane and practical reasons to develop self-help group supportive policies. Policies described here that could be implemented by clinicians and program managers include making greater use of empirically-validated self-help group referral methods in both specialty and non-specialty treatment settings and developing a menu of locally available self-help group options that are responsive to clients needs, preferences, and cultural background. The workgroup also offered possible self-help supportive policy options (e.g., supporting self-help clearinghouses) for state and federal decision makers. Implementing such policies could strengthen alcohol and drug self-help organizations, and thereby enhance the national response to the serious public health problem of substance abuse.

Alcoholics Anonymous Effectiveness: Faith Meets Science

ABSTRACT Research on the effectiveness of Alcoholics Anonymous (AA) is controversial and subject to widely divergent interpretations. The goal of this article is to provide a focused review of the literature on AA effectiveness that will allow readers to judge the evidence effectiveness of AA for themselves. The review organizes the research on AA effectiveness according to six criterion required for establishing causation: (1) magnitude of effect; (2) dose response effect; (3) consistent effect; (4) temporally accurate effects; (5) specific effects; (6) plausibility. The evidence for criteria 1- 4 and 6 is strong: rates of abstinence are about twice as high among those who attend AA (criteria 1, magnitude); higher levels of attendance are related to higher rates of abstinence (criteria 2, dose-response); these relationships are found for different samples and follow-up periods (criteria 3, consistency); prior AA attendance is predictive of subsequent abstinence (criteria 4, temporal); and mechanisms of action predicted by theories of behavior change are present in AA (criteria 6, plausibility). However, rigorous experimental evidence establishing the specificity of an effect for AA or Twelve Step Facilitation/TSF (criteria 5) is mixed, with 2 trials finding a positive effect for AA, 1 trial finding a negative effect for AA, and 1 trial finding a null effect. Studies addressing specificity using statistical approaches have had two contradictory findings, and two that reported significant effects for AA after adjusting for potential confounders such as motivation to change.

An alternative to standard drinks as a measure of alcohol consumption

Despite the fields longstanding concern with underreporting of alcohol consumption, traditional survey questions encourage error because respondents often must calculate their number of drinks based on standard drink sizes that often do not match their own drinking style. This study considered how often respondents self-defined drink sizes matched a standard drink size based on approximately 12 g of ethanol for six different beverages. We also studied whether respondents could accurately judge the size of their drinks. Subjects were recruited and interviewed at urban prenatal clinics, health clinics, and via snowball referrals and community outreach in Los Angeles and the San Francisco Bay Area. Because of the urgency of accurate measurement of consumption during pregnancy, urban pregnant women from the groups most at risk for Fetal Alcohol Syndrome, Native Americans (n = 102) and African Americans (185), were targeted. A small comparison group of urban pregnant white women (n = 34) was included. One-hour in-person interviews were conducted. Self-defined drink sizes were determined for each beverage consumed, using models and photographs of vessels. Frequent drinkers and the majority of women who reported drinking higher alcohol content beverages reported drinking larger-than-standard drink sizes. The median size of a malt liquor drink among the daily drinkers was almost three times as large as the standard, their fortified wine drinks were four times the standard, and their spirits drinks were six times the standard size. The majority of drinkers of each beverage were unable to accurately judge the size of their drinks, underestimating the number of fluid ounces by about 30%. Although the vessels methodology used here must be refined and tested further on other populations (e.g., men, nonpregnant women, and all ethnic groups), results suggest that determination of risk levels should be based on survey data that takes into consideration the beverage mix and the actual size of respondents alcohol drinks.

Effectiveness of Making Alcoholics Anonymous Easier: A group format 12-step facilitation approach

Most treatment programs recommend clients attend 12-step groups, but many drop out posttreatment. The effectiveness of Making Alcoholics Anonymous [AA] Easier (MAAEZ ), a manual-guided intervention designed to help clients connect with individuals encountered in AA, was tested using an OFF/ON design (n = 508). MAAEZ effectiveness was determined by comparing abstinence rates of participants recruited during ON and OFF conditions and by studying the effect of the number of MAAEZ sessions attended. At 12 months, more clients in the ON condition (vs. OFF) reported past 30-day abstinence from alcohol (p = .012), drugs (p = .009), and both alcohol and drugs (p = .045). In multivariate analyses, ON condition participants had significantly increased odds of abstinence from alcohol (odds ratio [OR] = 1.85) and from drugs (OR = 2.21); abstinence odds also increased significantly for each additional MAAEZ session received. MAAEZ appeared especially effective for those with more prior AA exposure, severe psychiatric problems, and atheists/agnostics. MAAEZ represents an evidence-based intervention that is easily implemented in existing treatment programs.

Twelve-Step affiliation and 3-year substance use outcomes among adolescents: social support and religious service attendance as potential mediators

AIMSnTwelve-Step affiliation among adolescents is little understood. We examined 12-Step affiliation and its association with substance use outcomes 3 years post-treatment intake among adolescents seeking chemical dependency (CD) treatment in a private, managed-care health plan. We also examined the effects of social support and religious service attendance on the relationship.nnnDESIGNnWe analyzed data for 357 adolescents, aged 13-18, who entered treatment at four Kaiser Permanente Northern California CD programs between March 2000 and May 2002 and completed both baseline and 3-year follow-up interviews.nnnMEASURESnMeasures at follow-up included alcohol and drug use, 12-Step affiliation, social support and frequency of religious service attendance.nnnFINDINGSnAt 3 years, 68 adolescents (19%) reported attending any 12-Step meetings, and 49 (14%) reported involvement in at least one of seven 12-Step activities, in the previous 6 months. Multivariate logistic regression analyses indicated that after controlling individual and treatment factors, 12-Step attendance at 1 year was marginally significant, while 12-Step attendance at 3 years was associated with both alcohol and drug abstinence at 3 years [odds ratio (OR) 2.58, P < 0.05 and OR 2.53, P < 0.05, respectively]. Similarly, 12-Step activity involvement was associated significantly with 30-day alcohol and drug abstinence. There are possible mediating effects of social support and religious service attendance on the relationship between post-treatment 12-Step affiliation and 3-year outcomes.nnnCONCLUSIONSnThe findings suggest the importance of 12-Step affiliation in maintaining long-term recovery, and help to understand the mechanism through which it works among adolescents.

Long‐term effects of alcohol warning labels: Findings from a comparison of the United States and Ontario, Canada

Since 1989 the U.S. federal government has required warnings on alcohol containers. Findings are presented from telephone surveys conducted between 1990 and 1994 in the U.S. and Ontario, Canada, the no-treatment reference site. In the U.S., penetration peaked in 1993–94, with 43% of the lifetime drinkers reporting label awareness. Label exposure was weaker (<20%) for all years in the reference site. The proportion reporting conversations about drinking during pregnancy was higher among label seers in both sites. Those seeing labels in the U.S. were more likely to engage in conversations about drinking and driving than those not seeing. Reports of limiting drinking for health reasons showed a positive association with label exposure increasing with time. In the U.S. only, across all years, controlling for age, gender, education, and alcohol consumption, label seers were more likely to drive after drinking too much, but also to say they had deliberately not driven after drinking during the last year. Findings from this quasi-experiment cannot establish causal relationships, but the pattern of results, though mixed, suggests modest effects on conversations and several precautionary behaviors related to risks of drinking. The labels effects may partially offset an overall trend toward lower public concern about health risks of alcohol. Results are interpreted as consistent with Congressional intent to remind people of certain hazards of drinking, especially during pregnancy or before driving vehicles.

What do women get out of self-help? their reasons for attending women for sobriety and alcoholics anonymous

It has been variously argued in the literature on women and alcohol that there is insufficient evidence to determine whether there is a need for women to be treated separately and differently from alcoholic men; that the findings are mixed; that the treatment characteristics that are more or less effective with women still are not known; and that some types of treatment are indeed best for women. This paper considers reasons for distinct treatment approaches for alcoholic women and considers in depth one such solution: Women For Sobriety (WFS). Using data from the first comprehensive survey of the WFS membership (response rate = 73%, n = 600), the reasons given by respondents for attending WFS and Alcoholics Anonymous (AA), and for not attending AA, are presented. Respondents said they attend WFS for support and nurturance (54%), for a safe environment (26%), for sharing about womens issues (42%), and because of its positive emphasis (38%) and focus on self esteem (39%). They attend AA primarily as insurance against relapse (28%), for its wide availability (25%), and for sharing (31%) and support (27%). Women who do not attend AA mentioned feeling as though they never fit in at AA (20%), finding AA too negative (18%), disliking the drunkalogs (14%) and their focus on the past (14%), and feeling that AA is geared to mens needs (15%). To provide a context for understanding what WFS members get out of attending WFS that they do not get out of AA, a brief description of WFS and a comparison between WFS and AA are provided. Implications for treatment referral are also discussed.

Does Diagnosis Matter? Differential Effects of 12-Step Participation and Social Networks on Abstinence

Previous studies that have examined the effects of specific aspects of 12-step participation and social network composition on abstinence have focused mostly on alcohol-related outcomes and have screened out drug dependent persons. This article explores whether these predictors differentially affect abstinence based on DSM-III-R substance dependence disorder (alcohol dependence, drug dependence, and both alcohol and drug dependence). A heterogeneous community sample of treatment seekers (N = 302) randomized to day treatment programs were followed at 6 and 12 months. Bivariate and multivariate regression models were used to test whether engagement in 12-step practices and social network influences to drink or use drugs predicted total abstinence from alcohol and drugs differentially by dependence disorder. Chi-square automatic interaction detector (CHAID) segmentation analyses were then conducted to identify the specific 12-step activities and social network thresholds that best distinguished higher rates of abstinence in each dependence category. Results showed that the number of 12-step meetings attended and number of prescribed 12-step activities engaged in similarly predicted abstinence for alcoholics, drug addicts, and those dependent on both alcohol and drugs. However, specific activities were associated with abstinence differentially by dependence disorder. While many activities differentiated abstinence for drug addicts and those dependent on both alcohol and drugs, for alcoholics only two Alcoholics Anonymous (AA) activities distinguished abstinence (having a sponsor and doing service). Key predictors of abstinence (CHAID) varied by follow-up and dependence disorder, except for doing service in AA and/or Narcotics Anonymous, which was the only specific 12-step activity that was a best predictor of abstinence in all three categories one year following treatment. Thus, “giving back” to ones peer community through service work, an important 12-step belief, seems to be universally valuable later in recovery. As for social network influences, a multivariate regression model showed that having a higher proportion of abstinent individuals in the network was associated with abstinence for alcoholics at 6 months only and for drug dependent persons at 12 months only. CHAID models supported these results and provided specific thresholds for 12-step measures (e.g., >20 meetings for alcoholics, 2 or more nondrinkers in the social network, 3 or more persons supporting reduction for those dependent on both alcohol and drugs, and having 2 or more nondrinkers for those dependent on drugs only). These results support the value of treatment providers prioritizing certain 12-step-related practices and social network changes based on their client dependence profiles. Early on, those with an alcohol diagnosis need to make a commitment to meetings and obtain a sponsor; also, they need to place themselves in a network that encourages sobriety. Early on, those who are drug-dependent-only especially need to become connected with 12-step programs to the extent that they consider themselves a member, and, later, saturate themselves in a highly supportive and predominantly nondrinking environment. Alcohol and drug dependent clients need more intense ongoing 12-step involvement (sponsor and meetings) as well as having nondrinking individuals and people supportive of abstinence in their network. For all clients, doing service is especially important at the longer 12-month posttreatment timeframe.

Regular articleEffectiveness of Making Alcoholics Anonymous Easier: A group format 12-step facilitation approach

Most treatment programs recommend clients attend 12-step groups, but many drop out posttreatment. The effectiveness of Making Alcoholics Anonymous [AA] Easier (MAAEZ ), a manual-guided intervention designed to help clients connect with individuals encountered in AA, was tested using an OFF/ON design (n = 508). MAAEZ effectiveness was determined by comparing abstinence rates of participants recruited during ON and OFF conditions and by studying the effect of the number of MAAEZ sessions attended. At 12 months, more clients in the ON condition (vs. OFF) reported past 30-day abstinence from alcohol (p = .012), drugs (p = .009), and both alcohol and drugs (p = .045). In multivariate analyses, ON condition participants had significantly increased odds of abstinence from alcohol (odds ratio [OR] = 1.85) and from drugs (OR = 2.21); abstinence odds also increased significantly for each additional MAAEZ session received. MAAEZ appeared especially effective for those with more prior AA exposure, severe psychiatric problems, and atheists/agnostics. MAAEZ represents an evidence-based intervention that is easily implemented in existing treatment programs.

Participation in alcoholics anonymous: intended and unintended change mechanisms.

This article is a compilation of the information presented at a symposium at the 2001 RSA Meeting in Montreal, Canada. The presentations were: (1) Maintaining change after conjoint behavioral alcohol treatment for men: the role of involvement with Alcoholics Anonymous, by Barbara S. McCrady and Elizabeth E. Epstein; (2) Changing AA practices and outcomes: Project MATCH 3-year follow-up, by J. Scott Tonigan; (3) Life events and patterns of recovery of AA-exposed adults and adolescents, by Patricia L. Owen and Valerie Slaymaker; (4) Social networks and AA involvement as mediators of change, by Lee Ann Kaskutas and Keith Humphreys; and (5) What do we know about Alcoholics Anonymous? by William R. Miller, discussant.