Drug-Dependent Patients Attending AA: How Do They Do?
Drug-Dependent Patients Attending AA: How Do They Do?
Participants were 279 young adults (18–24 years old) undergoing residential treatment in Minnesota in the USA and enrolled in an observational study of treatment process and outcome. At admission, participants were 20.4 years old on average (SD = 1.6). Most were Caucasian (95.0%) and male (73.4%), while all were single (100%). At admission, 40.6% were employed and 32.5% were students. Most had completed high school: 42.7% had a high school diploma and 39.2% had some college education. Participants in this private treatment sample were more likely to be Caucasian than young adults (18–24 years old) in public sector residential treatment (76%) (Substance Abuse and Mental Health Services Administration, 2009). They were, however, comparable in terms of gender, marital status and employment status, suggesting that results are broadly generalizable to youth treated for substance-related disorders in the USA.
Treatment was comprehensive and multi-faceted, based in a 12-step philosophy of recovery. In addition to the 12-step orientation, motivational enhancement and cognitive-behavioral therapeutic approaches, as well as family therapy, were used to facilitate problem recognition, increase treatment engagement and to support recovery. Programming included clinical assessment, individual and group therapy, and a host of specialty groups tailored to meet the needs of individual clients. Integrated mental health care was available, including clinical assessment, psychotherapy and medication management. Participants' average length of stay was 25.7 days (SD = 5.6, ranging = 4–35 days). The majority (83.9%) were discharged with staff approval, indicating a high rate of treatment completion.
Participants were enrolled in the study shortly after admission. A total of 607 young adults were admitted to treatment during the recruitment period (10/2006 to 3/2008). All of those aged 21–24 years old were approached for study enrollment, as well as every second individual aged 18–20. This was done to ensure sufficient representation of the older age group, given the predominance of those aged 18–20 at the treatment center. Of those approached (n = 384), 64 declined or withdrew participation. Following enrollment, an additional 17 participants withdrew prior to the baseline assessment and the consent for one participant was misplaced. The final sample of 302 represents 78.6% of those approached for participation. To focus on this study's primary research questions, we excluded individuals who did not report a primary substance of choice (n = 3), reported more than one primary substance (n = 5), or reported a primary substance that was not alcohol, cannabis, opiates or stimulants (n = 15), which resulted in a final sample of 279.
Research staff conducted assessments at baseline, 3, 6 and 12 months post-discharge. Each assessment included an interview portion, completed either in person or by telephone, and self-administered surveys, which were returned by mail. Participants were reimbursed $30 for the baseline assessment and $30, $40 and $50 for the post-treatment assessments at 3, 6 and 12 months, respectively. Assessment completion rates were 81.2, 72.7 and 71.0% at the 3-, 6- and 12-month follow-ups, respectively. At each time point, those who did not complete the assessment were compared with those who were retained in terms of gender, age, race, education, employment status, and baseline psychological symptoms (BSI), dependence severity (LDQ) and percent days of abstinence in the 90 days prior to treatment (α = 0.05). Relative to those with post-secondary education, those with a high school education or less were more likely to be missed at all time points.
The study was conducted in accordance with the Institutional Review Board at Schulmann Associates IRB, an independent review board, and all participants signed informed consent documents.
Background sociodemographic information, including age, gender, marital status, race and ethnicity, employment status, educational attainment, and student status, was obtained with participants' full permission, from their medical records.
Structured Clinical Interview for DSM-IV-TR. The Structured Clinical Interview for DSM-IV-TR (SCID) (First et al., 2002) was conducted by trained personnel at baseline to assess SUD diagnoses. To ensure inter-rater reliability and protocol fidelity, supervisory reviews of audio-taped SCID interviews were conducted on all assessments during the first month of data collection and for two randomly chosen interviews each week thereafter.
Leeds Dependence Questionnaire. The Leeds Dependence Questionnaire (LDQ) is a brief, 10-item self-report measure of dependence severity that is not specific to particular substances. Likert Scale responses are summed to provide a total score out of 30, with higher scores indicating greater dependence severity. The measure has shown high internal consistency (α = 0.93) and good construct validity in the present sample (Kelly et al., 2010b), and in other adult and youth samples (Raistrick et al., 1994; Lennings, 1999).
Form-90. The Form-90 (Project MATCH Research Group, 1993; Miller and Del Boca, 1994) is an interview measure capturing substance use in the past 90 days. Modifications were made to subsequent assessments to capture the time period elapsed since previous interview (i.e. averaging 90 days for the 3- and 6-month follow-ups, and 180 days for the 12-month follow-up). Patients' primary substance (aka 'drug of choice') and the primary outcome in the current study, percentage of days abstinent (PDA) from all substances except nicotine, were both derived from this instrument. The Form-90 has been tested with adult and adolescent samples and has demonstrated reliability and validity (Tonigan et al., 1997; Slesnick and Tonigan, 2004).
Inventory of Drug Use Consequences—Recent Consequences (InDUC-2R). The InDUC-2R is a 50-item self-report measure assessing consequences of alcohol and/or drug use. Items are rated in terms of their frequency of occurrence in the past 90 days, from never (0) to daily or almost daily (3) and are summed to provide a total score. The InDUC-2R has demonstrated sensitivity to changes in consequences over a 3-month period (Tonigan and Miller, 2002). Reliability in the current sample was very high (Cronbach's α = 0.95).
Multidimensional Mutual Help Activity Scale. This interview-based index assesses several dimensions of involvement in 12-step MHOs. Responses for each item are provided separately for AA and NA. Items tap frequency of attendance (which was also divided by total days in the follow-up assessment to create percent days attending a meeting), as well as level of active 12-step involvement which was measured by the total sum of 8 dichotomized activities, such as contact with sponsor and other members, step work, reading 12-step literature, and speaking at meetings). As with the Form-90, interviews captured the entire time period elapsed since the previous interview. Analysis of this measure in this same sample of young adults has shown high content validity and reliability (Kelly et al., 2011).
To verify self-reported abstinence from alcohol and other drugs, saliva tests (Cone et al., 2002) were administered on a subsample of subjects that lived within 50 miles of the treatment facility and could attend follow-up interviews in-person. Abstinence was confirmed in 99.6–100% of subjects who self-reported abstinence from all substances during the assessment period prior to each follow-up. Positive tests results were obtained for one subject who reported abstinence prior to the 3-month follow-up and this person was not included in the analysis.
We divided the sample into four groups based on patients' reported primary substance: alcohol, cannabis, opiates or stimulants. To compare between-group differences at baseline we used one-way ANOVA's and Chi-square tests. Significant between-group differences were further characterized using post hoc Tukey tests (continuous variables) and contrast statements in logistic regression models (categorical variables). We also compared number of meetings attended for each of AA and NA as a function of primary substance using the Kruskal–Wallis test. To account for multiple comparisons, we adjusted all post hoc tests using a Bonferroni correction. We then examined the effect of primary substance on 12-step attendance and involvement with hierarchical linear models (HLM) using Proc Mixed. To determine whether the trajectories in attendance and involvement differed across time between groups, we added in a group by time interaction term.
To evaluate the relative benefit of 12-step fellowship matching, we first combined the cannabis, opiate and stimulant groups to create a 'primary drug group'. Next, within this group, we divided the number of AA meetings attended by total 12-step meetings attended, to produce a variable the reflected the proportion of 12-step attendance that was theoretically 'mismatched', with higher proportions ostensibly indicating poorer matching of the primary drug group to AA. Using this variable, we constructed HLMs that tested the effect of this matching and the interaction between matching and time on subsequent 12-step attendance and involvement over the 12-month follow-up period among the primary drug patients only.
Lastly, to investigate the effect of fellowship mismatch among the primary drug group on substance use outcomes we used two HLMs which regressed percent days abstinent (PDA) on fellowship mismatch, attendance or involvement, and the interaction between fellowship match and attendance or involvement. In all HLM models, we controlled for predictors of attrition (education) and baseline levels of the dependent variable (e.g. 12-step attendance, 12-step involvement, percent days abstinent), respectively. To adhere to models' statistical assumptions, we transformed PDA using a negative log transformation. Appropriate covariance structures were selected using the likelihood ratio test. All analyses were generated using SAS Version 9.2.
Methods
Participants
Participants were 279 young adults (18–24 years old) undergoing residential treatment in Minnesota in the USA and enrolled in an observational study of treatment process and outcome. At admission, participants were 20.4 years old on average (SD = 1.6). Most were Caucasian (95.0%) and male (73.4%), while all were single (100%). At admission, 40.6% were employed and 32.5% were students. Most had completed high school: 42.7% had a high school diploma and 39.2% had some college education. Participants in this private treatment sample were more likely to be Caucasian than young adults (18–24 years old) in public sector residential treatment (76%) (Substance Abuse and Mental Health Services Administration, 2009). They were, however, comparable in terms of gender, marital status and employment status, suggesting that results are broadly generalizable to youth treated for substance-related disorders in the USA.
Treatment
Treatment was comprehensive and multi-faceted, based in a 12-step philosophy of recovery. In addition to the 12-step orientation, motivational enhancement and cognitive-behavioral therapeutic approaches, as well as family therapy, were used to facilitate problem recognition, increase treatment engagement and to support recovery. Programming included clinical assessment, individual and group therapy, and a host of specialty groups tailored to meet the needs of individual clients. Integrated mental health care was available, including clinical assessment, psychotherapy and medication management. Participants' average length of stay was 25.7 days (SD = 5.6, ranging = 4–35 days). The majority (83.9%) were discharged with staff approval, indicating a high rate of treatment completion.
Procedure
Participants were enrolled in the study shortly after admission. A total of 607 young adults were admitted to treatment during the recruitment period (10/2006 to 3/2008). All of those aged 21–24 years old were approached for study enrollment, as well as every second individual aged 18–20. This was done to ensure sufficient representation of the older age group, given the predominance of those aged 18–20 at the treatment center. Of those approached (n = 384), 64 declined or withdrew participation. Following enrollment, an additional 17 participants withdrew prior to the baseline assessment and the consent for one participant was misplaced. The final sample of 302 represents 78.6% of those approached for participation. To focus on this study's primary research questions, we excluded individuals who did not report a primary substance of choice (n = 3), reported more than one primary substance (n = 5), or reported a primary substance that was not alcohol, cannabis, opiates or stimulants (n = 15), which resulted in a final sample of 279.
Research staff conducted assessments at baseline, 3, 6 and 12 months post-discharge. Each assessment included an interview portion, completed either in person or by telephone, and self-administered surveys, which were returned by mail. Participants were reimbursed $30 for the baseline assessment and $30, $40 and $50 for the post-treatment assessments at 3, 6 and 12 months, respectively. Assessment completion rates were 81.2, 72.7 and 71.0% at the 3-, 6- and 12-month follow-ups, respectively. At each time point, those who did not complete the assessment were compared with those who were retained in terms of gender, age, race, education, employment status, and baseline psychological symptoms (BSI), dependence severity (LDQ) and percent days of abstinence in the 90 days prior to treatment (α = 0.05). Relative to those with post-secondary education, those with a high school education or less were more likely to be missed at all time points.
The study was conducted in accordance with the Institutional Review Board at Schulmann Associates IRB, an independent review board, and all participants signed informed consent documents.
Measures
Background sociodemographic information, including age, gender, marital status, race and ethnicity, employment status, educational attainment, and student status, was obtained with participants' full permission, from their medical records.
Structured Clinical Interview for DSM-IV-TR. The Structured Clinical Interview for DSM-IV-TR (SCID) (First et al., 2002) was conducted by trained personnel at baseline to assess SUD diagnoses. To ensure inter-rater reliability and protocol fidelity, supervisory reviews of audio-taped SCID interviews were conducted on all assessments during the first month of data collection and for two randomly chosen interviews each week thereafter.
Leeds Dependence Questionnaire. The Leeds Dependence Questionnaire (LDQ) is a brief, 10-item self-report measure of dependence severity that is not specific to particular substances. Likert Scale responses are summed to provide a total score out of 30, with higher scores indicating greater dependence severity. The measure has shown high internal consistency (α = 0.93) and good construct validity in the present sample (Kelly et al., 2010b), and in other adult and youth samples (Raistrick et al., 1994; Lennings, 1999).
Form-90. The Form-90 (Project MATCH Research Group, 1993; Miller and Del Boca, 1994) is an interview measure capturing substance use in the past 90 days. Modifications were made to subsequent assessments to capture the time period elapsed since previous interview (i.e. averaging 90 days for the 3- and 6-month follow-ups, and 180 days for the 12-month follow-up). Patients' primary substance (aka 'drug of choice') and the primary outcome in the current study, percentage of days abstinent (PDA) from all substances except nicotine, were both derived from this instrument. The Form-90 has been tested with adult and adolescent samples and has demonstrated reliability and validity (Tonigan et al., 1997; Slesnick and Tonigan, 2004).
Inventory of Drug Use Consequences—Recent Consequences (InDUC-2R). The InDUC-2R is a 50-item self-report measure assessing consequences of alcohol and/or drug use. Items are rated in terms of their frequency of occurrence in the past 90 days, from never (0) to daily or almost daily (3) and are summed to provide a total score. The InDUC-2R has demonstrated sensitivity to changes in consequences over a 3-month period (Tonigan and Miller, 2002). Reliability in the current sample was very high (Cronbach's α = 0.95).
Multidimensional Mutual Help Activity Scale. This interview-based index assesses several dimensions of involvement in 12-step MHOs. Responses for each item are provided separately for AA and NA. Items tap frequency of attendance (which was also divided by total days in the follow-up assessment to create percent days attending a meeting), as well as level of active 12-step involvement which was measured by the total sum of 8 dichotomized activities, such as contact with sponsor and other members, step work, reading 12-step literature, and speaking at meetings). As with the Form-90, interviews captured the entire time period elapsed since the previous interview. Analysis of this measure in this same sample of young adults has shown high content validity and reliability (Kelly et al., 2011).
Biological assay
To verify self-reported abstinence from alcohol and other drugs, saliva tests (Cone et al., 2002) were administered on a subsample of subjects that lived within 50 miles of the treatment facility and could attend follow-up interviews in-person. Abstinence was confirmed in 99.6–100% of subjects who self-reported abstinence from all substances during the assessment period prior to each follow-up. Positive tests results were obtained for one subject who reported abstinence prior to the 3-month follow-up and this person was not included in the analysis.
Data analysis plan
We divided the sample into four groups based on patients' reported primary substance: alcohol, cannabis, opiates or stimulants. To compare between-group differences at baseline we used one-way ANOVA's and Chi-square tests. Significant between-group differences were further characterized using post hoc Tukey tests (continuous variables) and contrast statements in logistic regression models (categorical variables). We also compared number of meetings attended for each of AA and NA as a function of primary substance using the Kruskal–Wallis test. To account for multiple comparisons, we adjusted all post hoc tests using a Bonferroni correction. We then examined the effect of primary substance on 12-step attendance and involvement with hierarchical linear models (HLM) using Proc Mixed. To determine whether the trajectories in attendance and involvement differed across time between groups, we added in a group by time interaction term.
To evaluate the relative benefit of 12-step fellowship matching, we first combined the cannabis, opiate and stimulant groups to create a 'primary drug group'. Next, within this group, we divided the number of AA meetings attended by total 12-step meetings attended, to produce a variable the reflected the proportion of 12-step attendance that was theoretically 'mismatched', with higher proportions ostensibly indicating poorer matching of the primary drug group to AA. Using this variable, we constructed HLMs that tested the effect of this matching and the interaction between matching and time on subsequent 12-step attendance and involvement over the 12-month follow-up period among the primary drug patients only.
Lastly, to investigate the effect of fellowship mismatch among the primary drug group on substance use outcomes we used two HLMs which regressed percent days abstinent (PDA) on fellowship mismatch, attendance or involvement, and the interaction between fellowship match and attendance or involvement. In all HLM models, we controlled for predictors of attrition (education) and baseline levels of the dependent variable (e.g. 12-step attendance, 12-step involvement, percent days abstinent), respectively. To adhere to models' statistical assumptions, we transformed PDA using a negative log transformation. Appropriate covariance structures were selected using the likelihood ratio test. All analyses were generated using SAS Version 9.2.
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