Evidence-Based 12-TreatmentEvidence-Based 12-Treatment for Adult Substance Abusefor Adult Substance Abuse

J. Scott Tonigan, PhDJ. Scott Tonigan, PhD

Center on Alcoholism, Substance Abuse and Addictions (CASAA)Center on Alcoholism, Substance Abuse and Addictions (CASAA)Department of PsychologyDepartment of PsychologyUniversity of New MexicoUniversity of New Mexico

Puerto Rico Addiction Research Foundation ConferencePuerto Rico Addiction Research Foundation ConferenceSan Juan, Puerto RicoSan Juan, Puerto Rico

March 15, 2013March 15, 2013

Presentation OverviewPresentation Overview

NIH Research MethodologyNIH Research Methodology

12- Step Treatment Effectiveness12- Step Treatment Effectiveness

Community AA & NA: What works?Community AA & NA: What works?

A Closing Comment & ConsiderationA Closing Comment & Consideration

NIH Research MethodologyNIH Research Methodology

• Three Common Study Designs:Three Common Study Designs:

–Randomized Clinical Trial (RCT)Randomized Clinical Trial (RCT)

–Longitudinal “Intact” GroupsLongitudinal “Intact” Groups

–Cross-SectionalCross-Sectional

Important ConsiderationsImportant Considerations

• Use of good self-report measures Use of good self-report measures andand corroboration between biomedical, corroboration between biomedical, collateral, and client reportcollateral, and client report

• Firewall between clinical and research Firewall between clinical and research staff staff

• Fidelity of treatment is critical; use of Fidelity of treatment is critical; use of therapy manualstherapy manuals

More Important ConsiderationsMore Important Considerations

• Follow-up rates > 70%Follow-up rates > 70%

• Advanced statistical models depicting Advanced statistical models depicting changes in substance use behavior.changes in substance use behavior.

• Peer-review of study findings before Peer-review of study findings before publicationpublication

Opiate Use CorroborationOpiate Use Corroboration

174 26

40 11

Urine Opiate ScreenUrine Opiate ScreenNegative PositiveSS

EELLFF

RREEPPooRRTT

NoNo

YesYes

37

51

200

214

Reliability of Self-reportedReliability of Self-reported12-step Meeting Attendance12-step Meeting Attendance

Rsq = 0.8571.0.9.8.7.6.5.4.3.2.10.0

100

90

80

70

60

50

40

30

20

10

0

Frequency ofFrequency of self-reported andself-reported and interviewer-based countsinterviewer-based counts 12-step meeting attendance12-step meeting attendance at 3-Month follow-upat 3-Month follow-up

(N = 206; r = .93)(N = 206; r = .93)

Self-report (GAATOR)Self-report (GAATOR)

Form 90Form 90InterviewInterview

0 0.75 1.50 2.25 3.00-0.07

21.89

43.84

65.79

87.75

TIME_L

ILLI

CT

b = -3.709972 p < .004

““Person-Centered” Hierarchical Linear ModelingPerson-Centered” Hierarchical Linear Modeling of Days Opiate Use over 12-monthsof Days Opiate Use over 12-months

Intake 12-Months

DaysDaysOpiateOpiateUseUse

N = 188

At eachFU opiateUse was reduced3 days

14

13

12

11

10

9

8

7

6

5

4

3

2

1

0

DaysSubstance Use/Past 30-Days

Intake 8-Week 16-Week 28-Week

Therapist Effects: The NEED for ManualsTherapist Effects: The NEED for Manuals

10 Therapists, each with five ormore clients

12-Step Treatment Effectiveness12-Step Treatment Effectiveness

Six

Project MATCH Design:Project MATCH Design:

Screen Randomize FU3 6 9 12 15 (39) (120)

Two Arms: Aftercare Sample N = 774, Outpatient Sample = 952

CBT

MET

TSF

98% 97% 95% 94% 92% 85%86%

Cognitive Behavioral TherapyCognitive Behavioral Therapy

Motivational Enhancement TherapyMotivational Enhancement Therapy

Twelve Step Twelve Step Facilitation Facilitation Therapy (TSF)Therapy (TSF)

Twelve Step Facilitation (TSF):Twelve Step Facilitation (TSF):

Adheres to the concepts and beliefs set forth in 12-step Adheres to the concepts and beliefs set forth in 12-step programs. The overall goal of TSF is to facilitate the programs. The overall goal of TSF is to facilitate the long-term engagement of clients into the fellowship of long-term engagement of clients into the fellowship of 12-step programs.12-step programs.

Substance misuse is a progressive illness that Substance misuse is a progressive illness that affects the body, mind, and spirit.affects the body, mind, and spirit.

Substance misuse is characterized by a completeSubstance misuse is characterized by a completeloss of control over substances that, if loss of control over substances that, if

unarrested, will result inunarrested, will result in death or insanity.death or insanity.

The only effective remedy is The only effective remedy is total abstinence, total abstinence, andanda clear distinction is made thata clear distinction is made that sobriety sobriety is the goal.is the goal.

Origin of 12-step programsOrigin of 12-step programs

AA was founded in the early thirties, AA was founded in the early thirties, and is intentionally and is intentionally non-professionalnon-professional

Two texts form the Two texts form the core core AA literatureAA literature

The Twelve Steps and the 12 TraditionsThe Twelve Steps and the 12 Traditionsa. The AA a. The AA Program (12-steps)Program (12-steps)b. The AA b. The AA Fellowship Fellowship

DRAFTDRAFT

““How it Works” ChapterHow it Works” Chapter

Big Book of Alcoholics AnonymousBig Book of Alcoholics Anonymous

The Manual:The Manual:Core AACore AALiteratureLiterature

1. We admitted we were powerless over alcohol—that our lives had become1. We admitted we were powerless over alcohol—that our lives had become unmanageable.unmanageable.  2. Came to believe that a Power greater than ourselves could restore us to sanity.2. Came to believe that a Power greater than ourselves could restore us to sanity.   3. Made a decision to turn our will and our lives over to the care of God 3. Made a decision to turn our will and our lives over to the care of God as we understood Him.as we understood Him.   4. Made a searching and fearless moral inventory of ourselves.4. Made a searching and fearless moral inventory of ourselves.  5. Admitted to God, to ourselves and to another human being the exact nature of our5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs.wrongs.  6. Were entirely ready to have God remove all these defects of character.6. Were entirely ready to have God remove all these defects of character.  7. Humbly asked Him to remove our shortcomings.7. Humbly asked Him to remove our shortcomings.  8. Made a list of all persons we had harmed, and became willing to make amends to8. Made a list of all persons we had harmed, and became willing to make amends to them all.them all.  9. Made direct amends to such people wherever possible, except when to do so would9. Made direct amends to such people wherever possible, except when to do so would injure them or others.injure them or others.  10.Continued to take personal inventory and when we were wrong promptly admitted10.Continued to take personal inventory and when we were wrong promptly admitted it.it.  11.Sought through prayer and meditation to improve our conscious contact with God,11.Sought through prayer and meditation to improve our conscious contact with God, as we understood Himas we understood Him, praying only for knowledge of His will for us and the power to , praying only for knowledge of His will for us and the power to carry that out.carry that out.  12.Having had a spiritual awakening as the result of these steps, we tried to carry this 12.Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.message to alcoholics, and to practice these principles in all our affairs.

12 Steps of AA: Prescribed Program Behaviors12 Steps of AA: Prescribed Program Behaviors

Surrender

Action

Maintenance

12-Step Meeting Attendance12-Step Meeting Attendance by MATCH Treatment Groupby MATCH Treatment Group

Intake 12 Month Intake 12 MonthIntake 12 Month Intake 12 Month

OUTPATIENT AFTERCAREOUTPATIENT AFTERCARE

Project MATCH (N = 1,729) Project MATCH (N = 1,729) Substance AbusersSubstance Abusers

Cognitive-Behavior vs Motivational Enhancement Therapies

Drinks per drinking day Percent abstinent days

What did we learn from thisWhat did we learn from this

“ “Treatment Effectiveness” Study?Treatment Effectiveness” Study?

1.1.Treatments with high fidelityTreatments with high fidelity produce good outcomes.produce good outcomes.

2. No one treatment “wins” the2. No one treatment “wins” the horse race.horse race.

One of the “big” surprises, however, One of the “big” surprises, however, was the relatively good showingwas the relatively good showingof 12-step therapy, and the superiorityof 12-step therapy, and the superiorityof this approach when of this approach when total abstinencetotal abstinencewas the treatment goal.was the treatment goal.

Why a surprise?Why a surprise?

90 Days 180 Days 270 Days 360 Days90 Days 180 Days 270 Days 360 DaysEnd of TreatmentEnd of Treatment

ProportionProportionAvoidingAvoidingFirst First DayDaySubstanceSubstanceUseUse

.80.80

.60.60

.40.40

.20.20

TSF: 24%TSF: 24%CBT: 15%CBT: 15%MET: 14%MET: 14%

Significant Delay in Days to First Drink in TSF Significant Delay in Days to First Drink in TSF Relative to CBT & MET Relative to CBT & MET

AbstinentAbstinent

35

30

25

20

15

10

5

0

Percent Abstinent from AlcoholPercent Abstinent from AlcoholAndAnd Abstinent from Alcohol & Drugs Abstinent from Alcohol & Drugs

CBT MET TSFCBT MET TSF

PercentPercentAbstinentAbstinentAt 1-YearAt 1-YearOutpatientOutpatient

Intact Group Studies: 12-Step Intact Group Studies: 12-Step Treatment with Drug Dependent Treatment with Drug Dependent

AdultsAdults

Christo & Franey (1995): 8 Residential and Outpatient CentersChristo & Franey (1995): 8 Residential and Outpatient Centers12-step attendance encouraged/not required12-step attendance encouraged/not required(N = 101)(N = 101)

Gossop et al. (2007): 8 Inpatient 15 Residential Programs (total 23)Gossop et al. (2007): 8 Inpatient 15 Residential Programs (total 23)12-step in 6/8 Inpatient; 7/15 Residential12-step in 6/8 Inpatient; 7/15 Residential(N = 142)(N = 142)

Florentine (1999) 26 Outpatient Drug Treatment Centers Florentine (1999) 26 Outpatient Drug Treatment Centers 12-step and eclectic12-step and eclectic(N = 419)(N = 419)

Intact Group FindingsIntact Group Findings

• Christo & Franey: At 6 month FU, Christo & Franey: At 6 month FU, significantly fewer drug use days for significantly fewer drug use days for patients that attended NA (r = -.31).patients that attended NA (r = -.31).

• Florentine: At 24 month FU, 73% of 12-Florentine: At 24 month FU, 73% of 12-step attender’s were abstinent and 56% step attender’s were abstinent and 56% of non-attender’s were abstinent.of non-attender’s were abstinent.

Intact Group FindingsIntact Group Findings

Gossop et al: At 12-month FU, PercentGossop et al: At 12-month FU, PercentAbstinentAbstinent

Attend Attend Did NotDid Not12-Step12-Step Attend 12-Step Attend 12-Step

Opiates (Heroin)Opiates (Heroin) 69%69% 37%37%

CocaineCocaine 86%86% 60%60%

AlcoholAlcohol 63%63% 34%34%

Community-based AA & NA Community-based AA & NA ProgramsPrograms

12-step Treatment is evidence-based 12-step Treatment is evidence-based and facilitation into community- and facilitation into community- based 12-step programs is a critical based 12-step programs is a critical aspect of this approach.aspect of this approach.

Who is most likely to attend a 12-Who is most likely to attend a 12-step community-based program?step community-based program?

Are these meetings widely available?Are these meetings widely available?

Number and Location of 12-step Number and Location of 12-step Meetings in the 1940sMeetings in the 1940s

Number and Location of 12-Step Number and Location of 12-Step Meetings NowMeetings Now

Number and Location of 12-step Number and Location of 12-step Meetings GloballyMeetings Globally

12-step Meeting LocationsIn Puerto Rico

100 Narcotics Anonymous Meetings 100 Narcotics Anonymous Meetings (21 in San Juan)(21 in San Juan)

236 Alcoholics Anonymous Meetings 236 Alcoholics Anonymous Meetings (59 in San Juan)(59 in San Juan)

38 Alanon Meetings38 Alanon Meetings

Predictors of 12-step Attendance (Tonigan et al.)Predictors of 12-step Attendance (Tonigan et al.)

r r weightedweighted SD SD CorrectedCorrected

Loss of ControlLoss of Control .26.26 .00.00

Daily UseDaily Use .26.26 .00.00

Physical DependencePhysical Dependence .23.23 .16.16

Severity of DependenceSeverity of Dependence .18.18 .25.25

24 Other Affiliation Characteristics were less than r = .12, 24 Other Affiliation Characteristics were less than r = .12, e.g., gender, social stability, education, age, and religiouse.g., gender, social stability, education, age, and religiousaffiliation.affiliation.

Drug Dependent SamplesDrug Dependent Samples

• Weiss et al. (2000). Cocaine dependent adultsWeiss et al. (2000). Cocaine dependent adults (N = 411) randomized to 4 treatments.(N = 411) randomized to 4 treatments.

1. Higher ASI Drug Severity (Intake) predicted 1. Higher ASI Drug Severity (Intake) predicted higher 12-step attendance at 1 and 6-month higher 12-step attendance at 1 and 6-month FU.FU.

2. Higher days use of cocaine before trt (30 2. Higher days use of cocaine before trt (30 days) predicted significantly higher rates of days) predicted significantly higher rates of 12-12-step attendance at 1 and 6-month FU.step attendance at 1 and 6-month FU.

What Explains 12-step Benefit?What Explains 12-step Benefit?

TRACE Study Design (N = 253)

OutpatientOutpatientTreatmentTreatment

Community-Community-BasedBased

AAAA

3 6 9 12 18 243 6 9 12 18 24

Follow-up Rates: Follow-up Rates: 3 = 94%3 = 94% 6 = 94%6 = 94%

9 = 92%9 = 92% 12 = 91% 12 = 91%

12-step Sponsor12-step Sponsor

• Sponsorship represents the intersection of 12-Sponsorship represents the intersection of 12-step program & fellowship prescriptions.step program & fellowship prescriptions.

• Sponsor guides one through the 12-stepsSponsor guides one through the 12-steps

• Sponsor is available on a day-by-day basisSponsor is available on a day-by-day basis

Early 12-step Sponsorship

AA Sponsor (1-3 MO)AA Sponsor (1-3 MO)

YesYes No No

(n =75)(n =75) (n=107) (n=107)Months 4-6Months 4-6

Percent Alcohol AbstinentPercent Alcohol Abstinent 56%56% 24%24%

Percent Alcohol & Illicit drgsPercent Alcohol & Illicit drgs 45%45% 19%19%

Proportion Abstinent DaysProportion Abstinent Days .91 .91 .70.70

Drinks per Drinking DayDrinks per Drinking Day 5.435.43 7.737.73

Early 12-step Sponsorship and Substance Use Over Time

Proportion Abstinent Days by EarlyProportion Abstinent Days by Early Sponsor StatusSponsor Status

Follow-up 3 -12 Months Follow-up 3 – 12 MonthsFollow-up 3 -12 Months Follow-up 3 – 12 Months

Sponsor

No Sponsor

Drinks per Drinking Day by EarlyDrinks per Drinking Day by Early Sponsor StatusSponsor Status

No Sponsor

Sponsor

Do Social Networks and Support for Do Social Networks and Support for Abstinence Explain 12-step Benefit?Abstinence Explain 12-step Benefit?

15 Studies 15 Studies Tonigan & Rice (2012)Tonigan & Rice (2012)Humphreys et al. 1999Humphreys et al. 1999Humphreys & Noke, 1997aHumphreys & Noke, 1997aTimko et al., 2005Timko et al., 2005Humphreys et al., 1994Humphreys et al., 1994Ouimette et al., 1998Ouimette et al., 1998George & Tucker, 1996George & Tucker, 1996Laudet et al., 2004Laudet et al., 2004Kaskutas et al., 2002Kaskutas et al., 2002Bond, Kaskutas, et al., 2003Bond, Kaskutas, et al., 2003Witbrod & Kaskutas, 2005Witbrod & Kaskutas, 2005Humphreys et al., 1997bHumphreys et al., 1997bMcCrady et al., 2004McCrady et al., 2004Mankowski et al., 2001Mankowski et al., 2001Kelly et al. 2011Kelly et al. 2011

Outcome

SocialSupport

Abst.

12-stepMtg &Involv

8 studies .15 *8 studies .15 *

.22*.22*

All Paths Investigating Social Support All Paths Investigating Social Support Are SignificantAre Significant

5 Studies5 Studies

8 Studies .12*8 Studies .12*

Changes in SpiritualityChanges in Spirituality 12-step Exposed Groups12-step Exposed Groups

Increased Spiritual PracticesIncreased Spiritual Practices Predicts Decreased Substance UsePredicts Decreased Substance Use

StudyStudy 12-step to Abst12-step to Abst 12-step to S/P12-step to S/P S/P to AbstinenceS/P to Abstinence

Kaskutas (2003)Kaskutas (2003) b = .27*b = .27* ------ b = .25b = .25

Kelly (2011)Kelly (2011) ResidentialResidential b = .24*b = .24* b = .25*b = .25* b = .18*b = .18*

OutpatientOutpatient b = .21*b = .21* b = 14*b = 14* b = .21*b = .21*

Oakes (2008)Oakes (2008) b = .41*b = .41* b = .23*b = .23* b = .21*b = .21*

Robinson (2007)Robinson (2007) b = .02b = .02 ------ b = .05b = .05

Tonigan (2003)Tonigan (2003) b = .43*b = .43* b = .25*b = .25* b = .06b = .06

Tonigan (2012)Tonigan (2012) b = .41*b = .41* b = .21*b = .21* b = .19*b = .19*

Average effects b = .27 (.04) b = .22 (.06) b = .17 (.04)Average effects b = .27 (.04) b = .22 (.06) b = .17 (.04)

A Closing Comment & Consideration

We speak of 12-step meetings as if they are

are the same. Evidence suggests, however, that 12-step meetings differ

in fundamental ways and that these

differences are important.

Studies of 12-step Groups Using Studies of 12-step Groups Using the Group Environment Scalethe Group Environment Scale

• Some groups are more supportive and Some groups are more supportive and cohesive, others are more aggressive.cohesive, others are more aggressive.

• More supportive and cohesive groups are More supportive and cohesive groups are associatedassociated with higher rates of step work by with higher rates of step work by members and more sustained 12-step members and more sustained 12-step attendance.attendance.

• Members of more cohesive groups have Members of more cohesive groups have higher rates of abstinence at a later time.higher rates of abstinence at a later time.

(Lloyd-Rice & Tonigan, 2012 ; Rynes, Tonigan, & Rice, 2013)(Lloyd-Rice & Tonigan, 2012 ; Rynes, Tonigan, & Rice, 2013)

What is KnownWhat is KnownCombined, TSF and community-based 12-step Combined, TSF and community-based 12-step

programs produce high rates of abstinence.programs produce high rates of abstinence.

High rates of 12-step meeting attendance during High rates of 12-step meeting attendance during treatment predicts sustained attendance after treatment predicts sustained attendance after treatment. Meetings may differ, however.treatment. Meetings may differ, however.

Having a sponsor, increased social support, and Having a sponsor, increased social support, and S/P are to be encouraged because they explain S/P are to be encouraged because they explain whywhy 12-step attendance is important. 12-step attendance is important.