Mutual aid works, whether it’s 12 step, Lifering, SMART or WFS

photo credit: Jeff Tabaco

The Journal of Substance Abuse Treatment just published a study examining outcomes for 12 step groups and Lifering, Women for Sobriety (WFS), and SMART Recovery.

The researchers described their findings this way:

The present study contributes the first longitudinal, comparative data on 12-step groups and the largest secular, abstinence-based alternatives available in the U.S.: WFS, SMART, and LifeRing. Results revealed strong, robust associations between higher primary group involvement and all three outcomes across 6- and 12-month follow-ups, along with no significant interactions between primary group affiliation at baseline and 6-month primary group involvement in any model. These results tentatively suggest equivalent efficacy for WFS, LifeRing, and SMART, compared to 12-step groups. They suggest that mutual help group involvement—measured as meeting attendance; having a regular or home group; having a close friend or sponsor in the group; leading, convening, or facilitating meetings; and doing volunteer or service work—offers equivalent benefits in relation to substance use and problems regardless of group choice. Findings are noteworthy given the almost total lack of evidence on the efficacy of alternatives to the 12-step model in recovery from alcohol and drug abuse. Though findings should be confirmed in larger samples, they do support referral to a range of abstinence-focused alternatives to AA.

The study controlled for the differences in goals for the various groups. Vox posted a story about the study. They describe those findings this way:

The study, conducted by the Alcohol Research Group at the Public Health Institute in California and published last month in the Journal of Substance Abuse Treatment, surveyed more than 600 people with alcohol use disorder (AUD), who were divided by which mutual help group they primarily participated in. Researchers followed up at six months then 12 months, measuring involvement in the groups and various substance use outcomes, including abstinence from drinking and alcohol-related problems.

After controlling for several factors, the researchers concluded that “[Women for Sobriety], LifeRing, and SMART are as effective as 12-step groups for those with AUDs.”

“Essentially, that’s the story,” Zemore said. “We were really interested in whether the effects of involvement on recovery outcomes depended on which group [participants] were in. And we found that they did not.”

There were some differences in the data. People who reported SMART as their primary group seemed to have worse substance use outcomes, and there were lower odds of total abstinence among LifeRing members.

That might have something to do with differences in recovery goals. For example, AA really emphasizes total abstinence from drinking as the solution to alcohol addiction. Groups like SMART and LifeRing, meanwhile, can be friendlier to the idea of members moderating their drinking but not quitting altogether. That could affect substance use outcomes — and especially abstinence outcomes.

The study’s survey data suggests this is in fact what was going on: When researchers controlled for people’s recovery goals — meaning, whether they wanted to commit to lifetime total abstinence or not — the differences between the 12-step groups, SMART, and LifeRing went away.

“That suggests that people with less commitment to lifetime total abstinence are more likely to participate in SMART and LifeRing than they are to participate in 12-step groups,” Zemore said. “That’s why you’re seeing these associations between SMART and LifeRing affiliation at baseline and worse recovery outcomes when you control for involvement.” She added, “But I want to emphasize that these go away when you control for recovery goals.”

Building on existing research

Bill White has summarized research on various mechanisms of change in mutual aid groups (Look at page 128. It includes citations.):

  • problem recognition and commitment to change;
  • regular re-motivation to continue change efforts;
  • counter-norms that buffer the effects of heavy drinking social networks and alcohol and other drug use promotion in the wider culture;
  • sustained self-monitoring;
  • increased spiritual orientation;
  • enhanced coping skills, particularly the recognition of high-risk situations and stressors;
  • increased self-efficacy;
  • social support that offsets the influence of pro-drinking social networks;
  • helping others with alcohol and other drug problems;
  • exposure to sober role models and experience-based advice on how to stay sober;
  • participation in rewarding sober activities;
  • 24-hour accessibility of assistance; and
  • potentially lifelong supports that do not require financial resources.

This study has also provided further affirmation of studies finding that, while mutual aid attendance may predict some improvement in outcomes, mutual aid involvement (having a sponsor, a home group, service activities, social contact with friends in the group, etc.) is a much more potent predictor.

See also:

UPDATE:

Jeff Jay raises an important point in the comments below:

Having different goals (abstinence vs maybe abstinent) is what makes these groups’ outcomes “equivalent.” Which goes to show that if we control for the right factors, we can also make apples and oranges equivalent.

12-step members were more likely to be abstinent at follow-up.

If I understand correctly, as a secondary aim, the study controlled for the differences in goals by measuring whether the members achieved their goal. (Which may, or may not, be in the long term interests of themselves and their loved ones.)

The present study contributes the first longitudinal, comparative data on 12-step groups and the largest secular, abstinence-based alternatives available in the U.S.: WFS, SMART, and LifeRing. Results revealed strong, robust associations between higher primary group involvement and all three outcomes across 6- and 12-month follow-ups, along with no significant interactions between primary group affiliation at baseline and 6-month primary group involvement in any model. These results tentatively suggest equivalent efficacy for WFS, LifeRing, and SMART, compared to 12-step groups. They suggest that mutual help group involvement—measured as meeting attendance; having a regular or home group; having a close friend or sponsor in the group; leading, convening, or facilitating meetings; and doing volunteer or service work—offers equivalent benefits in relation to substance use and problems regardless of group choice.

As for their goals, the study reports on recovery goals this way:

our baseline PAL data suggested that LifeRing and SMART members have less stringent alcohol recovery goals than 12-step members: While large majorities of 12-step (72%) and WFS (67%) members endorsed a recovery goal of lifetime total abstinence, endorsement rates for this same goal were significantly lower among LifeRing members (58%) and lowest of all among SMART members (40%) (Zemore et al., 2017).

Interesting that 28% of 12-step members did not endorse a goal of lifetime abstinence. (I suppose these are new initiates who may not be totally sold on 12-step’s emphasis abstinence?)

 

1 Comment

Filed under Uncategorized

“alternative endpoints”?

I caught a few minutes of the White House opioid summit yesterday and the phrase “alternative endpoints” caught my attention.

That’s Alex Azar speaking. He’s the Secretary of Health and Human Services.

Here’s what he said [emphasis mine]:

At the NGA (National Governors Association) we also highlighted two forthcoming Food and Drug Administration guidances that will expand and accelerate medication-assisted treatment. One of them will help the development of long-acting depot formulations like the monthly shot that was approved this past fall, and one that will open up new ways of assessing medically-assisted treatment effectiveness by looking at metrics besides just achieving abstinence, complete abstinence, so alternative endpoints.

I have two problems with that statement.

  1. The idea that complete abstinence is the metric for medically-assisted treatment (MAT) effectiveness is just not true. I reviewed some of the most frequently cited evidence for MAT here. Most studies don’t even report information on abstinence.MAT With Methadone or Buprenorphine Assessing the Evidence for Effectiveness – Addiction Treatment Forum
  2. I have no objection to measuring outcomes like reduced drug use, mortality, criminal activity, or disease transmission. Those are important public health outcomes. I also have no objection to providing treatments to patients who do not choose abstinence as a goal. However, these measures as endpoints for researchers and treatment providers? Creating systems focused on these as “endpoints”? If that’s what they are proposing, that’s neglect.

I do not know the contents of Secretary Azar’s mind and I do not claim to know his  motives. However, it’s important to be aware of his perspective. Here’s a portion of his bio:

From 2001 to 2007, Azar served at the U.S. Department of Health and Human Services – first as its General Counsel (2001–2005) and then as Deputy Secretary. During his time as Deputy Secretary, Azar was involved in improving the department’s operations; advancing its emergency preparedness and response capabilities as well as its global health affairs activities; and helping oversee the rollout of the Medicare Part D prescription drug program.

In 2007, Azar rejoined the private sector as senior vice president for corporate affairs and communications at Eli Lilly and Co. From 2012 to 2017, he served as president of Lilly USA LLC, the company’s largest affiliate.

That doesn’t mean he’s an evil Pharma shill, but it does say something about his worldview, his networks, and it may be considered a conflict of interests.

Comments Off on “alternative endpoints”?

Filed under Uncategorized

Most People Who Overdose Don’t Die. Instead, They’re Ensnared In Relentless Cycle Of Worry And Chaos.

This headline is from the Kaiser Health News Morning Brief.

So much better than the last couple of headlines I shared.

Comments Off on Most People Who Overdose Don’t Die. Instead, They’re Ensnared In Relentless Cycle Of Worry And Chaos.

Filed under Uncategorized

“You get used to it pretty quickly”

Another day, another troubling headline.

If you believe that the access to “safer” drugs is the problem, maybe vending machines will “fix Vancouver’s drug crisis.”

For more than a decade, we’ve been told that Vancouver is the model the US should emulate. No North American city has been more aggressive in implementing harm reduction practices—safe injection rooms, heroin maintenance, hydromorphone (dilaudid) maintenance, crack pipe vending machines and, of course, all the less sensational forms of harm reduction.

So . . . all these years later, where are they at?

Last year, overdoses killed 1,422 people in British Columbia, the highest number ever, a 43 per cent increase over 2016.

Pretty discouraging.

The provincial CDC’s conclusion is that they have not gone far enough.

. . . sometime in the next several weeks, in March or April, Tyndall will launch a pilot program to distribute hydromorphone pills (a pharmaceutical narcotic derived from morphine) to registered users . . .

What’s it like there?

Vancouver’s Downtown Eastside, defined as a de facto colony for people who inject or smoke hard drugs, is smaller than it used to be—maybe half the 20 blocks it used to cover, with condo developments looming on all sides. On the warm January day when I visited, a lot of people are out, lining the sidewalks of East Hastings Street, a few side streets and many wide alleys off the main artery. Many are openly smoking or injecting drugs. It’s a shocking sight the first time you visit. You get used to it pretty quickly.

 

How many times does recovery come up in this article? 1 time, as a glib rebuttal that equates questioning the approach to malignant neglect.

“You can’t ask people to recover if they’re dead. But the stigma goes so deep that I think a lot of people go, ‘Well, who gives a shit? They die. Better for us. We don’t have to pay their medical bills.’ ”

What’s the animating belief? (emphasis mine)

Addiction, he says, is a chronic relapsing disease. Most addicts don’t stop.

If you believe that addicts don’t want to and are unable to stop, then this seems like a pragmatic and compassionate approach.

If you know that addicts hate their lives and that there is hope for recovery, this is very, very sad. If you know that the hopelessness of most addicts requires that professional helpers acts as hope carriers, this will make you angry.

This does not have to be an either/or matter. There is room for a both/and approach. However, as a casual observer, I have not seen BC public health officials, politicians, researchers, or policy advocates address the need and hope for recovery.

 

Comments Off on “You get used to it pretty quickly”

Filed under Uncategorized

“played a significant role in creating the necessary conditions for the U.S. opioid epidemic”

A new Senate report looks at financial relationships between opioid manufacturers and pain advocacy groups:

Sen. Claire McCaskill released a report Monday alleging that from 2012 to 2017, leading manufacturers of opioids gave $9 million to pain treatment advocacy groups, an arrangement the report says “may have played a significant role in creating the necessary conditions for the U.S. opioids epidemic.”

. . .

“Notably, a majority of these groups also strongly criticized 2016 guidelines from the Centers for Disease Control and Prevention that recommended limits on opioid prescriptions for chronic pain — the first national standards for prescription opioids and a key federal response to the ongoing epidemic.” McCaskill’s investigators concluded.

 

Comments Off on “played a significant role in creating the necessary conditions for the U.S. opioid epidemic”

Filed under Uncategorized

“Drug addicts to be given heroin in bid to tackle crime”

Take note of the headline and then ask yourself,

  • whose needs does this serve?
  • what beliefs underlie the plan?
  • what values/priorities underlie the plan?

 

3 Comments

Filed under Uncategorized

It’s a complicated issue with a lot of factors at play

Very few articles about addiction have the seriousness and integrity to look past easy answers and simple narratives.

Nieman Reports recently published an article by Susan Stellin that is the best I’ve read in as long as I can remember.

The article addresses issues of evidence-based practices, research, journalistic bias toward the drama of addiction over the ordinariness of recovery, pessimism about recovery, corruption among treatment providers (medical and non-medical), and Derek Wolfe’s Healing Forest Project.

She closes with this comment from a reporter that’s been writing about addiction with a focus on her region:

That is perhaps the most important advice Ungar has for anyone newer to the beat: “Whenever anyone says, ‘This way is the best way,’ I’m skeptical of that. Having spent years covering addiction, I’ve seen people on all sides of the issue, so when I encounter someone who’s an evangelist for one type of treatment over another, I think as a reporter you have to step back and say, ‘This is not black and white.’ It’s a complicated issue with a lot of factors at play.”

I have my strongly held belief that everyone should be offered the same kind of care physicians with addiction get, but I also believe that they ought to have access to the legitimate treatment of their choice.

 

 

 

 

1 Comment

Filed under Uncategorized