12-Step as Aftercare:
Predictors and Effectiveness

Principal Investigator: Alexandre B. Laudet, PhD, NDRI

Co-Investigator: Shiela Strauss, PhD, NDRI

Funding Source: National Institute on Drug Abuse
Grant 1 R01 DA015133

Funding period: 4/5/03-3/31/07


Abstract and Specific Aims:

Participation in treatment has consistently been shown to be effective in reducing substance use and associated risks, especially among clients who remain in treatment for a longer duration. Because of the chronic nature of addiction however, treatment gains are often not maintained after discharge. Addiction specialists and treatment providers all stress the importance of continuing "step-down" care as necessary to solidify and maintain treatment gains. Preliminary evidence suggests that the approach is promising but most studies have focused on inpatient client populations whereas outpatient treatment is the most prevalent modality. Identifying effective aftercare modalities is particularly crucial in the current climate of decreasing duration and intensity of formal treatment services. Twelve-step groups (12SG) are the most widely available and least expensive form of aftercare. Affiliation with 12SG both during and after treatment appears helpful in complementing and extending treatment effects. As with formal treatment, longer duration and higher level of 12SG affiliation are associated with better outcomes. However, as with treatment, the dropout rate tends to be high, particularly after the first 6-months and some individuals never attend. Sustaining the original recovery is part of the ongoing recovery process. As formal services are being reduced, clients' outcome may be increasingly influenced by the degree to which treatment programs help clients take maximum advantage of 12SG so that an important task for treatment providers is to facilitate clients' transition into the post-treatment phase of recovery. Post-treatment 12SG affiliation can be regarded as a proximal outcome of treatment that in turn predicts later substance use. Specific formal treatment approaches can enhance client's post-treatment 12SG affiliation and benefits derived from affiliation. However, little is known about factors that predict 12SG affiliation or about how potential members become and stay involved; even less is known about reasons for disengagement or about barriers to affiliation. A greater understanding of these issues can enable professionals to focus practices in ways that would facilitate substance abuse clients' transition into 12SG.

The vast literature on 12SG has contributed greatly to current knowledge but remains critically limited in several ways. Sample limitations: 1) A nearly exclusive focus of Alcoholics Anonymous regardless of substances participants use: Narcotics Anonymous has over 25,000 meetings and a growing membership, yet its utilization and effectiveness have rarely been examined. 2) Until recently, the use of predominantly alcoholic samples. One cannot assume that the findings from these studies apply to illicit polysubstance users who make up the bulk to the treatment population. Drug-using clients differ from alcoholic-only clients in several critical ways that bear on long-term prognosis. 3) The use of predominantly Caucasian, male samples. Women and members of ethnic minorities suffer disproportionately the consequences of drug use and have been underrepresented in all 12SG studies. In terms of scope: 4) Little is known about predictors of affiliation 5) Predictor variables measured only once. Repeated measures are needed to capture the dynamic interplay among individual and contextual factors bearing on affiliation and outcomes over time; and 6) failure to address possible self-selection bias systematically so that the 'true' effect of 12SG (as distinct from self-selection effects) is unknown.

This study is a prospective, process-oriented investigation of predictors of NA and AA affiliation and their effectiveness on substance use and related outcomes over 12-months after discharge from treatment; 300 randomly-selected drug users will be recruited at intake in 2 large publicly-funded inner-city treatment programs in New York City; assessments will be repeated at discharge, and at 3-, 6-, and 12-months post-discharge. The specific aims are:

  1. To identify predictors of proximal (3- and 6-months post discharge) and distal (12-months) post-treatment affiliation with AA and NA among illicit drug users
  2. a) To assess the effectiveness of 12SG affiliation on proximal and distal outcomes during the 12-months post treatment period adjusting for self-selection biases; and
    b) To examine the processes underlying the effect of 12SG affiliation on outcome over time.
  3. To gain a greater understanding of choice of fellowship (NA and/or AA), disengagement from 12SG and barriers to affiliation among illicit drug users by conducting in-depth ethnographic studies.

The analyses to address these aims will be guided by a conceptual model building on previous research findings. Subgroup analyses will be conducted by gender and ethny as well as for NA and AA affiliation.

There are several unique aspects to this study that will contribute to filling critical gaps in current knowledge about 12SG; they include the focus on illicit drug-users and large subgroups (women and ethnic minorities) who have been under-represented in prior studies, the examination of affiliation with Narcotics Anonymous, the use of repeated measurements to test an empirically-driven model of 12SG processes, and the systematic examination of self-selection and mediators of 12SG that will inform on the direct effect (unique contribution) of 12SG affiliation on outcome. In addition to focusing on these under-investigated issues, the proposed study will speak to factors that promote or impede clients' transition into the post-treatment phase of recovery. Humphreys and colleagues noted the need to focus more effort on how formal and informal care system for substance abuse problems can function synergetically to help individuals recover. This important topic has received little consideration. A greater understanding of these issues can enable professionals to focus practices in ways that would facilitate substance abuse clients' transition into 12SG.

Publications and Presentations:

Laudet, A., Stanick, V., Carway, J., and Sands, B. (2004) Perceptions of Narcotics and Alcoholics Anonymous among polysubstance users
newly admitted to outpatient treatment. Poster Presented at 132nd APHA Annual Meeting of the American Public Health Association, Washington, DC

Morgen, K., Laudet, A., Stanick, V., Carway, J., Sands, B. Toward an Integrated Predictive Model of 12-Step Affiliation

Stanick, V., Laudet, A., Morgen K., Carway, J., Sands B. The Role of “Intent to Seek Treatment” Among Drug Users Legally Mandated to Treatment

Laudet, Stanick, Morgen, Carway & Sands. (2005) Role of client early treatment evaluation in post-treatment recovery promoting cognitions and activities. 133rd Annual Meeting of the APHA, Philadelphia.

Morgen, Laudet, Stanick, Carway & Sands The role of on-Site 12-Step meeting as Predictor of 12-Step Attendance and support for abstinence after outpatient treatment. Poster presented, 68th Annual Scientific Meeting of the College on Problems of Drug Dependence (CPDD), Scottsdale, AZ, 6/06

Stanick, Laudet, Morgen, Carway & Sands Early treatment evaluation as predictor of proximal and distal post-treatment recovery outcomes. Poster presented, 68th Annual Scientific Meeting of the College on Problems of Drug Dependence (CPDD), Scottsdale, AZ, 6/06

Laudet, A., Stanick, V. & Sands, B. (2007) The effect of onsite 12-step meetings on post-treatment outcomes among polysubstance-dependent outpatient clients. Evaluation Review, 31(6), 613-646.

Stanick, V. Laudet, A. & Sands. B. (2007) Role of individual, treatment, and post-treatment factors on sustained remission: examining gender differences Oral presentation at the 69th Annual Scientific Meeting of the College on Problems of Drug Dependence (CPDD), Quebec, Canada

Stanick, V. Laudet, A. & Sands. B.(2008). Will I stay or will I go? Role of early treatment experiences in predicting attrition. Presented at the 70th Annual Scientific Meeting of the College on Problems of Drug Dependence (CPDD), San Juan, Puerto Rico.

Laudet, A., Stanick, V. & Sands, B. (in press) What could the program have done differently? A qualitative examination of reasons for leaving outpatient treatment. J. Substance Abuse Treatment

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