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Background: The term "recovery" is widely used in the substance abuse literature and clinical settings, but data have not been available to empirically validate how recovery is defined by individuals who are themselves in recovery. The "What Is Recovery?" project developed a 39-item definition of recovery based on a large nationwide online survey of individuals in recovery. The objective of this paper is to report on the stability of those definitions one to two years later. Methods: To obtain a sample for studying recovery definitions that reflected the different pathways to recovery, the parent study involved intensive outreach. Follow-up interviews (. n=. 1237) were conducted online and by telephone among respondents who consented to participate in follow-up studies. Descriptive analyses considered endorsement of individual recovery items at both surveys, and t-tests of summary scores studied significant change in the sample overall and among key subgroups. To assess item reliability, Cronbach's alpha was estimated. Results: Rates of endorsement of individual items at both interviews was above 90% for a majority of the recovery elements, and there was about as much transition into endorsement as out of endorsement. Statistically significant t-test scores were of modest magnitude, and reliability statistics were high (ranging from .782 to .899). Conclusions: Longitudinal analyses found little evidence of meaningful change in recovery definitions at follow-up. Results thus suggest that the recovery definitions developed in the parent "What Is Recovery?" survey represent stable definitions of recovery that can be used to guide service provision in Recovery-Oriented Systems of Care.

Objective: Much of what we know about the course of alcohol consumption in problem and dependent drinkers comes from studies of in-treatment populations. Less is known about the natural course of alcohol consumption among such drinkers in the general population and what predicts how much they drink.Method: This study examined alcohol consumption over the course of 11 years in a randomly selected sample of 672 problem and dependent drinkers from a single, heterogeneous U.S. county.Results: Alcohol consumption declined and leveled off over time but did not decrease to the average general U.S. population level. Several indicators of ongoing problems with drinking are associated with high levels of drinking over time: having a heavy-drinking network, receiving suggestions to do something about one's drinking, and going to treatment. Factors associated with less drinking include having contact with community agencies and going to Alcoholics Anonymous (AA).Conclusions: Results suggest that problem and dependent drinkers continue to drink at an elevated level over the course of years. Gatekeepers, family members, and policymakers should encourage and facilitate contact with social service agencies and with AA for problem drinkers. Suggestions from others to do something about one's drinking and seeking specialty care occur more often in those with more severe problems and do not appear to be linked to less drinking over time. [ABSTRACT FROM AUTHOR]

The Institute of Medicine and Project MATCH have promoted the concept that various treatment programs are equally effective. Yet little attention has been paid to common treatment models in current use. This paper compares three dominant models evident in public and private substance abuse treatment today: the Minnesota Model, the California Social Model Programs, and the addiction Therapeutic Community. We explore their common roots in Alcoholics Anonymous (AA), and how each approach selectively borrowed particular AA principles (e.g., abstinence as the goal, reliance on the experiential knowledge of recovery, etc.) while rejecting others (i.e., Therapeutic Communities adapted some of AA's 12 steps, but without spirituality as an ingredient). We then examine the dominant forces that were exerted on these emerging treatment approaches, including the development of the treatment industry (with alcoholics and drug addicts initially treated separately, but later merged), the professionalization of counselor roles (with Social Model Programs most vulnerable), and managed care to achieve cost containment. The current status of each model is presented which indicates that the differences among them had significantly narrowed by the year 2000. Homogeneity among models raises the issue of when a treatment center can legitimately identify itself as using a specific model: How can a policy maker, funder, or researcher be assured that a treatment center operates with its advertised model? Finally, we discuss the common therapeutic ingredient that remains: the peer-group process. [ABSTRACT FROM AUTHOR]

Since the 1970s, much of the public treatment system in California has been based on a social model orientation to recovery for alcoholics, but there has been minimal research on program outcomes. This article reports on follow-up interviews conducted with a representative sample of 722 people who had entered treatment about a year earlier in public and private programs, including publicly-funded social model detoxification and residential programs, and clinical model programs in hospitals and HMO clinics. Social model clients came to treatment with more severe legal and employment problems, whereas those seeking treatment at clinical programs reported more severe family problems. At follow-up, clients at both types of programs reported attending a similar number of Alcoholics Anonymous (AA) meetings, but social model clients reported going to more Narcotics Anonymous (NA) meetings and being involved in more AA activities. Social model clients were less likely than clinical model clients to report problems with alcohol or drugs at follow-up, but the odds of reporting other problems (e.g., medical, psychological, legal, family/social) were similar. The program effect for better alcohol outcomes at the social model programs was partially explained by their clients' higher levels of 12-step program involvement during follow-up, which strongly predicted an absence of alcohol problems. Social networks supportive of abstinence also were predictive of reporting no alcohol problems at follow-up. In contrast, subsequent detoxification treatment events between baseline and follow-up were associated with a higher odds of reporting alcohol, drug, psychiatric and family/social problems at follow-up. These findings are consistent with the growing body of literature reporting higher rates of abstinence among those who are able to construct more positive social networks, and who attend and become involved in 12-step programs during and following treatment. It is important that these results be replicated, as they suggest that social model programs are successful in engaging their clients in AA activities and in NA meeting attendance, and could represent for some an effective alternative to clinical model treatment programs. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

BACKGROUND: Little is known about beverage preference, especially among understudied urban minority populations. Also, most studies do not differentiate between beer and malt liquor or among wine, wine coolers, and fortified wine. This article examines whether ethnicity or drinking frequency are associated with beverage choice, considering six types of alcoholic beverages: beer, wine, spirits, malt liquor, fortified wine, and wine coolers. METHODS: Data were analyzed from Native American (n = 70) and African American (n = 129) urban pregnant women who reported drinking in the 12 months before an index pregnancy. A small comparison group of white women (n = 22) was included. Women were queried about their consumption of each of six beverage types during the 12 months before pregnancy. RESULTS: The alcoholic beverage most often used, adjusted for other beverages consumed, was beer, followed in order by spirits, wine coolers, malt liquor, wine, and fortified wine. The Native American women preferred beer, which accounted for one third of total intake. In contrast, malt liquor and spirits each accounted for approximately a quarter of intake among African Americans. Compared with other drinkers, women who drank daily were significantly more likely to choose the beer and wine products with a higher alcohol content. In general, these bivariate results were borne out by multivariate analyses that controlled for age, marital status, and education. CONCLUSIONS: These findings suggest that when accuracy is desired, alcohol studies focusing on urban African American samples (and, to a lessor degree, Native American respondents) should consider not just beer, wine, and spirits consumption, but also stronger beer products, such as malt liquor; stronger wine products, such as fortified wine; and sweeter products, such as wine coolers. [ABSTRACT FROM AUTHOR]

BACKGROUND: Little is known about urban American Indian and African American women's drinking during pregnancy, or their beliefs about the risk of doing so. However, rates of fetal alcohol syndrome (FAS) are believed to be highest among those ethnic groups. METHODS: The Developing Effective Educational Resources (DEER) project recruited pregnant American Indian, African American, and white women from urban California areas (n = 321), to develop culturally appropriate consumption measures, to gather epidemiological data about drinking during pregnancy, and to assess exposure and reactions to health warnings intended to encourage abstinence during pregnancy. RESULTS: The study found high levels of exposure to health warnings among all ethnic groups, but many women were unclear about the actual consequences of FAS, about the risk of drinking even beer or wine or wine coolers, or about the value of reducing intake at any time during pregnancy. The majority of the women who drank malt liquor, fortified wine, wine, and spirits reported having larger than standard drinks, and daily drinkers had the highest levels of reporting error. When drink size was considered in the calculation of alcohol volume, average daily volume of consumption during pregnancy increased to the FAS risk level (average daily volume > or = 1) in the overall sample and among the African American and white subjects. CONCLUSIONS: Because some women, especially heavy drinkers, will continue drinking despite exposure to abstention-oriented health messages, it may be prudent to develop campaigns and interventions that provide factual information to help at-risk women reduce their drinking during pregnancy. Women could be advised of beverage equivalency, of standard drink sizes, and of how their own drinks compare with standard ones. Reliance on standard drink sizes in research can result in significant underreporting of consumption, especially among pregnant risk drinkers. [ABSTRACT FROM AUTHOR]

Background: Substance use disorder (SUD) resolution typically involves a long-term, comprehensive process of change now widely referred to as "recovery." Yet, definitions of recovery vary substantially, producing significant confusion. To support formal recovery definitions, we aimed to systematically identify recovery elements that are central to those in recovery and shared regardless of subgroup/pathway., Methods: Data were from the What is Recovery? Study, involving a diverse, national, online survey of people in recovery (N = 9341). Surveys included a 35-item recovery measure reflecting 4 domains; participants reported whether or not each element definitely belonged in their recovery definitions. Analyses examined item endorsements overall and among 30 subgroups defined a priori (by sociodemographics, substance use characteristics, and help-seeking history) to determine where items met study-specific centrality thresholds (ie, endorsement by ⩾80% and top-10 ranking, by endorsement level). We then classified items as "core" if meeting centrality thresholds both overall and for all 30 subgroups, and "prevalent" if meeting centrality thresholds overall and for 26 to 29 subgroups., Results: Four "core" recovery elements emerged, including a process of growth or development; being honest with oneself; taking responsibility for the things one can change; and reacting in a more balanced way. Four "prevalent" recovery elements also emerged, referencing the ability to enjoy life and handle negative feelings without substance use; abstinence and/or nonproblematic substance use; and living a life that contributes. Subgroups differing most in their endorsements included those reporting mild/moderate SUD severity; non-abstinent recovery; and no specialty treatment or mutual-help group attendance., Conclusions: Recovery elements identified here partially reflect some stakeholder definitions, but offer greater specificity and include novel elements (eg, personal integrity). Elements may point to areas of functioning that are damaged in the addiction process and can support an addiction-free life. Findings should inform institutional recovery definitions; SUD services and research; and communications about recovery., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Background: Researchers have developed several instruments to measure recovery capital-the social, physical, human, and cultural resources that help people resolve alcohol and other drug problems. However, existing measures are hampered by theoretical and psychometric weaknesses. The current study reports on process and psychometric outcomes for the Multidimensional Inventory of Recovery Capital (MIRC), a novel measure of recovery capital., Methods: We used a three-phase, mixed methods approach to develop the MIRC. Individuals who identified as having resolved alcohol problems were recruited in each phase. Phase one focused on item development, with participants providing qualitative feedback on potential items. In phase two (pilot testing) and phase three (final psychometric evaluation), participants completed revised versions of the MIRC to assess its psychometric strength and item performance., Results: Phase one (n=44) resulted in significant item alteration, culminating in a 48-item pilot measure. Pilot testing analyses (n=497) resulted in the deletion or replacement of 17 items. In the final psychometric evaluation (n=482), four additional items were deleted, resulting in a 28-item MIRC comprising four subscales measuring social, physical, human, and cultural capital. The psychometric properties of the final MIRC and its subscales ranged from sound to strong, with high response variability suggesting appropriate item discrimination., Conclusion: Results confirm the psychometric strength of the MIRC and underscore the importance of incorporating the insights of diverse samples of people in recovery. The MIRC holds promise as an assessment tool in future research and is available for use at no cost in treatment and community-based settings., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Introduction: During the COVID-19 pandemic, online video platforms became the primary mode of accessing substance use-focused mutual-help group meetings, which may persist after in-person meetings are available again. This study examined the characteristics (demographic, substance use and recovery, and mutual-help group use) of attendees of online recovery support meetings, and associations of online meeting attendance with substance use outcomes, using national data (without ensured representativeness) collected before the pandemic., Methods: Data were from the Peer Alternatives in Addiction (PAL) Study of attendees of 12-step groups (e.g., Alcoholics Anonymous), Women for Sobriety (WFS), LifeRing Secular Recovery (LifeRing), and SMART Recovery (SMART). The baseline sample, collected in 2015 (pre-pandemic), was 647 adults with lifetime alcohol use disorder who were surveyed online at baseline and 6-month (81%) and 12-month follow-up (83%)., Results: At baseline, 62% (n = 402) had attended an online mutual-help group meeting in their lifetime, and 36% (n = 236) had done so in the past 30 days. Bivariate analyses found that online meeting attendance was more likely among women than men, younger than older participants, and participants with more recent alcohol and drug use, and less abstinence self-efficacy. In addition, online meeting attendance was more likely among respondents who attended two or more different types of mutual-help groups (rather than just one type), and whose primary group was 12-step or WFS rather than LifeRing or SMART. Longitudinal analyses found an interaction between online meeting attendance (yes or no) and time on the outcomes of alcohol and total abstinence such that, compared to those who did not attend online meetings, online meeting attendees were less likely to be abstinent at baseline but were about the same on abstinence at 12 months. However, the interaction effect was attenuated when the model adjusted for mutual-help use characteristics., Conclusions: The findings inform mutual-help groups, providers, and researchers' efforts to sustain and expand this resource by suggesting that online meeting attendance may have appeal and be helpful to mutual-help group members who are earlier in their recovery., (Copyright © 2022. Published by Elsevier Inc.)

This study tests a socioecological model of relapse and recovery using latent class growth mixture modeling to identify neighborhood, social network and individual-level predictors of alcohol dependence trajectories among a large, longitudinal sample of problem drinkers recruited from substance use treatment settings. We identified four distinct alcohol dependence trajectories: Stable Recovery/Low (Class 1); Relapsing/Rising (Class 2); Late Recovery/Declining (Class 3); and Chronic/High (Class 4). Neighborhood context (poverty and density of bars), social network characteristics (less involvement with Alcoholics Anonymous [AA], continued affiliation with heavy drinkers), and individual predisposing (psychiatric severity) and need (returning to treatment) characteristics each distinguished individuals in the Relapsing/Rising class from individuals in the Stable Recovery/Low class. Social network characteristics (AA involvement and continued affiliation with heavy drinkers) were the primary distinguishing factors for individuals in the Chronic/High class compared to the Late Recovery/Declining class. Study findings can be used to promote recovery and help prevent relapse by: guiding development of community-level interventions to improve social and physical environments; identifying potentially modifiable factors (social network support for sobriety, participation in self-help) to reduce negative consequences among problem drinkers who remain in high-risk neighborhoods; and contributing to ongoing discussions about new and continued licensing of alcohol outlets and regulation of alcohol sales to prevent alcohol problems in high-risk areas and among high-risk people., Competing Interests: Declaration of conflicting interests:The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2020.)

Objectives: To evaluate the efficacy of an innovative, self-administered, electronic Screening and Brief Intervention (e-SBI) in English and Spanish, "DrinkWise," for reducing drinking among nonpregnant women of childbearing age., Methods: A parallel design, phase 1 trial included 185 nonpregnant women reporting risky drinking (8 or more drinks in a week or 3 or more drinks in a day) who were recruited from 2 publicly funded Nutritional Assistance for Women, Infants and Children (WIC) program sites in the United States from 2016 to 2017. Participants were 18 to 44 years in age, 75% of Hispanic ethnicity, 44% Spanish speakers, 30% had not completed high school, and 15% were currently breastfeeding. Participants were randomized to receive (intervention condition, n = 99) or not receive (control condition, no intervention, n = 86) DrinkWise and followed at 3 and 6 months., Results: Women receiving DrinkWise had greater reductions in the odds of self-reported weekly alcohol use (odds ratio [OR] = 0.22, SE = 0.12, P < 0.01) and heavy alcohol use (OR = 0.23, SE = 0.14, P < 0.05) at 6-month follow-up than controls, with no group differences at 3-month follow-up. Compared with heavy drinking controls, heavy drinkers receiving DrinkWise showed a trend (P = 0.06) for greater reductions in drink (pour) size from 3- to 6-month follow-up., Conclusions: DrinkWise may be efficacious in reducing drinking among low-income women of childbearing age and provides a low-cost tool for increasing access to recommended SBI among childbearing-age women. Studies should continue to build DrinkWise's evidence base., Trial Registration: ClinicalTrials.gov, https://clinicaltrials.gov/ct2/show/NCT02337361.

Purpose: We examined whether alcohol-dependent individuals with sustained substance use or psychiatric problems after completing treatment were more likely to experience low social status and whether continued help-seeking would improve outcomes., Short Summary: Ongoing alcohol, drug and psychiatric problems after completing treatment were associated with increased odds of low social status (unemployment, unstable housing and/or living in high-poverty neighborhood) over 7 years. The impact of drug problems declined over time, and there were small, delayed benefits of AA attendance on social status., Method: Alcohol-dependent individuals sampled from public and private treatment programs (N = 491; 62% male) in Northern California were interviewed at treatment entry and 1, 3, 5 and 7 years later. Random effects models tested relationships between problem severity (alcohol, drug and psychiatric problems) and help-seeking (attending specialty alcohol/drug treatment and Alcoholics Anonymous, AA) with low social status (unemployment, unstable housing and/or living in a high-poverty neighborhood) over time., Results: The proportion of participants experiencing none of the indicators of low social status increased between baseline and the 1-year follow-up and remained stable thereafter. Higher alcohol problem scores and having any drug and/or psychiatric problems in the years after treatment were associated with increased odds of low social status over time. An interaction of drug problems with time indicated the impact of drug problems on social status declined over the 7-year period. Both treatment-seeking and AA attendance were associated with increased odds of low social status, although lagged models suggested there were small, delayed benefits of AA attendance on improved social status over time., Conclusion: Specialty addiction treatment alone was not sufficient to have positive long-term impacts on social status and social integration of most alcohol-dependent people.

Background: Despite the effectiveness of 12-step groups, most people reporting a prior alcohol use disorder (AUD) do not sustain involvement in such groups at beneficial levels. This highlights the need for research on other mutual help groups that address alcohol problems and may attract those who avoid 12-step groups. The current study addresses this need, offering outcome data from the first longitudinal, comparative study of 12-step groups and their alternatives: The Peer ALlternatives for Addiction (PAL) Study., Methods: Adults with a lifetime AUD were surveyed at baseline (N=647), 6months (81% response rate) and 12months (83% response rate). Members of the largest known secular mutual help alternatives, namely Women for Sobriety (WFS), LifeRing, and SMART, were recruited in collaboration with group directors; current 12-step attendees were recruited from an online meeting hub. Online surveys assessed demographic and clinical variables; mutual help involvement; and alcohol and drug use and severity. Analyses involved multivariate logistic GEEs separately modelling alcohol abstinence, alcohol problems, and total abstinence across 6 and 12months. Key predictors were baseline primary group affiliation (PGA); primary group involvement (PGI) at both baseline and 6months; and the interaction between baseline PGA and 6-month PGI. The critical effects of interest were the interactions, expressing whether associations between changes in PGI from baseline to 6months and substance use outcomes differed by primary group., Results: None of the interactions between baseline PGA and 6-month PGI were significant, suggesting no differences in the efficacy of WFS, LifeRing, or SMART, vs. 12-step groups. Nevertheless, some PGA main effects emerged. Compared to 12-step members, those identifying SMART as their primary group at baseline fared worse across outcomes, and those affiliating with LifeRing showed lower odds of total abstinence. Still, these effects became nonsignificant when controlling for baseline alcohol recovery goal, suggesting that any group differences may be explained by selection of those with weaker abstinence motivation into LifeRing and (especially) SMART., Conclusions: This study makes a valuable contribution in view of the extremely limited evidence on mutual help alternatives. Results tentatively suggest that WFS, LifeRing, and SMART are as effective as 12-step groups for those with AUDs, and that this population has the best odds of success when committing to lifetime total abstinence. An optimal care plan may thus involve facilitating involvement in a broad array of mutual help groups and supporting abstinence motivation., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: As insurance coverage, funding sources and venues for drug and alcohol treatment evolve in the United States, it is important to assess how the type of treatment received may impact long-term outcomes. The current study aims were to examine effects of treatment type on alcohol consumption in the year after treatment intake and to test mediators of effects of treatment type on later alcohol use., Methods: Longitudinal data from clients in inpatient and outpatient alcohol treatment programs in California (n = 560) were used in ordinary least squares path analysis adjusting for respondent characteristics typically associated with both treatment completion and alcohol use. The primary outcome was amount of alcohol consumed in the 12 months after treatment entry; hypothesized mediators were treatment duration and participation in Alcoholics Anonymous (AA)., Results: Despite higher baseline problem severity and a shorter treatment duration, inpatient clients consumed less alcohol after treatment than outpatient clients (B [95% CI] = -0.95 [-1.67, -0.23]). AA involvement was a significant mediator of the relationship between treatment type and alcohol consumption, with inpatient clients being more involved in AA and also drinking less after treatment than outpatient clients; the bias-corrected bootstrap 95% confidence interval for the indirect effect (B = -0.20) was entirely below zero (-0.43 to -0.05)., Conclusions: Outpatient clients may benefit from customized posttreatment recommendations to identify additional resources to assist in the recovery process during the first year after treatment.

Socioecological approaches to public health problems like addiction emphasize the importance of person-environment interactions. Neighborhood and social network characteristics may influence the likelihood of relapse among individuals in recovery, but these factors have been understudied, particularly with respect to conceptualizing social network characteristics as moderators of neighborhood disadvantage. Drawing from a larger prospective study of individuals recruited from outpatient treatment (N=451) and interviewed 1, 3, 5, and 7 years later, the aim of this study was to examine the independent and interactive effects of neighborhood and social network characteristics on continued problem drinking after treatment. Models using generalized estimating equations controlling for demographic and other risk factors found the number of heavy drinkers in one's network increases risk of relapse, with the effects being significantly stronger among those living in disadvantaged neighborhoods than among those in non-disadvantaged neighborhoods. No independent effects were found for neighborhood disadvantage or for the number of network members supporting reduced drinking. Future research is needed to examine potential protective factors in neighborhoods which may offset socioeconomic disadvantage as well as to investigate the functions that network members serve in helping to improve long-term treatment outcomes., Competing Interests: Disclosures: No other authors have competing or conflicting financial interests.

Background: Distance and travel time are barriers to attending and completing drug and alcohol treatment. Few studies have examined proximity to treatment in relation to long-term outcomes., Objectives: Aims were to examine effects of distance to treatment on alcohol consumption in the year after treatment intake; assess moderation of distance effects by treatment type; and test mediators of effects of distance to treatment on later alcohol use., Methods: Data from clients in inpatient and outpatient alcohol treatment programs in California (n=560) were used in linear regression models., Results: There was a significant interaction between treatment type and distance on later drinking, with a significant positive association of distance to treatment with alcohol use after treatment for inpatient clients only. Among inpatient clients, none of the mediators significantly explained the relationship between a longer distance to treatment and greater subsequent alcohol use., Conclusion: Inpatient clients may benefit from customized post-treatment recommendations to identify recovery resources near home., Competing Interests: Declarations of Interest The authors have no conflicts of interest to report. Funding for the current analysis was received from the National Institute on Alcohol Abuse and Alcoholism grant R01AA020328. The original longitudinal study was supported by NIAAA grants R01AA09750, P50AA005595, and R01AA015927. The NIAAA had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

Background: Many studies suggest that participation in 12-step groups contributes to better recovery outcomes, but people often object to such groups and most do not sustain regular involvement. Yet, research on alternatives to 12-step groups is very sparse. The present study aimed to extend the knowledge base on mutual help group alternatives for those with an alcohol use disorder (AUD), sampling from large, active, abstinence-focused groups including Women for Sobriety (WFS), LifeRing, and SMART Recovery (SMART). This paper presents a cross-sectional analysis of this longitudinal study, using baseline data to describe the profile and participation characteristics of attendees of these groups in comparison to 12-step members., Methods: Data from participants 18 and over with a lifetime AUD (N=651) were collected using Web-based surveys. Members of alternative 12-step groups were recruited in collaboration with group directors, who helped publicize the study by emailing meeting conveners and attendees and posting announcements on social media. A comparison group of current (past-30-day) 12-step attendees was recruited from an online meeting hub for recovering persons. Interested parties were directed to a Webpage where they were screened, and eligible participants completed an online survey assessing demographic and clinical variables; in-person and online mutual help involvement; and group satisfaction and cohesion. Analyses involved comparing those identifying WFS, SMART, and LifeRing as their primary group to 12-step members on the above characteristics., Results: Compared to 12-step members, members of the mutual help alternatives were less religious and generally higher on education and income. WFS and LifeRing members were also older, more likely to be married, and lower on lifetime drug and psychiatric severity; meanwhile, LifeRing and SMART members were less likely to endorse the most stringent abstinence goal. Finally, despite lower levels of in-person meeting attendance, members of all the 12-step alternatives showed equivalent activity involvement and higher levels of satisfaction and cohesion, compared to 12-step members., Conclusions: Results suggest differences across 12-step groups and their alternatives that may be relevant when advising clients on a choice of mutual help group. Meanwhile, findings for high levels of participation, satisfaction, and cohesion among members of the mutual help alternatives suggest promise for these groups in addressing addiction problems., Competing Interests: None., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The What is Recovery? (WIR) study identified specific elements of a recovery definition that people in substance abuse recovery from multiple pathways would endorse., Objectives: To explain how participatory research contributed to the development of a comprehensive pool of items defining recovery; and to identify the commonality between the specific items endorsed by participants as defining recovery and the abstract components of recovery found in four important broad recovery definitions., Methods: A four-step, mixed-methods, iterative process was used to develop and pretest items (August 2010 to February 2012). Online survey recruitment (n = 238) was done via email lists of individuals in recovery and electronic advertisements; 54 were selected for in-depth telephone interviews. Analyses using experientially-based and survey research criteria resulted in a revised item pool of 47 refined and specific items. The WIR items were matched with the components of four important definitions., Results: Recovering participants (1) proposed and validated new items; (2) developed an alternative response category to the Likert; (3) suggested criteria for eliminating items irrelevant to recovery. The matching of WIR items with the components of important abstract definitions revealed extensive commonality., Conclusions/importance: The WIR items define recovery as ways of being, as a growth and learning process involving internal values and self-awareness with moral dimensions. This is the first wide-scale research identifying specific items defining recovery, which can be used to guide service provision in Recovery-Oriented Systems of Care.

Background: The term "recovery" is widely used in the substance abuse literature and clinical settings, but data have not been available to empirically validate how recovery is defined by individuals who are themselves in recovery. The "What Is Recovery?" project developed a 39-item definition of recovery based on a large nationwide online survey of individuals in recovery. The objective of this paper is to report on the stability of those definitions one to two years later., Methods: To obtain a sample for studying recovery definitions that reflected the different pathways to recovery, the parent study involved intensive outreach. Follow-up interviews (n=1237) were conducted online and by telephone among respondents who consented to participate in follow-up studies. Descriptive analyses considered endorsement of individual recovery items at both surveys, and t-tests of summary scores studied significant change in the sample overall and among key subgroups. To assess item reliability, Cronbach's alpha was estimated., Results: Rates of endorsement of individual items at both interviews was above 90% for a majority of the recovery elements, and there was about as much transition into endorsement as out of endorsement. Statistically significant t-test scores were of modest magnitude, and reliability statistics were high (ranging from .782 to .899)., Conclusions: Longitudinal analyses found little evidence of meaningful change in recovery definitions at follow-up. Results thus suggest that the recovery definitions developed in the parent "What Is Recovery?" survey represent stable definitions of recovery that can be used to guide service provision in Recovery-Oriented Systems of Care., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: The lack of established sampling frames makes reaching individuals in recovery from substance problems difficult. Although general population studies are most generalizable, the low prevalence of individuals in recovery makes this strategy costly and inefficient. Though more efficient, treatment samples are biased., Aims: To describe multi-source recruitment for capturing participants from heterogeneous pathways to recovery; assess which sources produced the most respondents within subgroups; and compare treatment and non-treatment samples to address generalizability., Results: Family/friends, Craigslist, social media and non-12-step groups produced the most respondents from hard-to-reach groups, such as racial minorities and treatment-naïve individuals. Recovery organizations yielded twice as many African-Americans and more rural dwellers, while social media yielded twice as many young people than other sources. Treatment samples had proportionally fewer females and older individuals compared to non-treated samples., Conclusions: Future research on recovery should utilize previously neglected recruiting strategies to maximize the representativeness of samples.

Background: Six percent of American adults say they are "in recovery" from an alcohol or drug problem yet only a scant emergent literature has begun to ask how they define "recovery" or explored whether there is heterogeneity among their definitions., Methods: Secondary analysis of the "What is Recovery?" online survey employed latent class analysis (LCA) to identify typologies of study participants based on their actual endorsement of 39 recovery elements and to compare the composition of these typologies in terms of distinguishing personal characteristics., Results: A five-class solution provided the best fit and conceptual representation for the recovery definitions. Classes were labeled 12-step traditionalist (n=4912); 12-step enthusiast (n=2014); secular (n=980); self-reliant (n=1040); and atypical (n=382) based on patterns of endorsement of the recovery elements. Abstinence, spiritual, and social interaction elements differentiated the classes most (as did age and recovery duration but to a lesser extent). Although levels and patterns of endorsement to the elements varied by class, a rank-ordering of the top 10 elements indicated that four elements were endorsed by all five classes: being honest with myself, handling negative feelings without using, being able to enjoy life, and process of growth and development., Conclusions: The results of the LCA demonstrate the diversity of meanings, and varying degrees of identification with, specific elements of recovery. As others have found, multiple constituents are invested in how recovery is defined and this has ramifications for professional, personal, and cultural processes related to how strategies to promote recovery are implemented., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

This paper addresses the assumption that pathways to recovery from substance abuse and dependence, and the language used to define one's relationship to substances, translate to actual beliefs and behaviors in terms of substance use. We draw on social representation theory, and use data from a large web-based study (n=9,341) whose goal was to understand how individuals in recovery define what recovery means to them. We often hear people say that they are "in recovery," and present findings now provide empirical evidence of the prevalent meanings of this ubiquitous expression. The belief that recovery is abstinence was broadly held in our sample, especially among those exposed to treatment and 12-step self-help groups and who define themselves as in recovery -and most (but not all) of such individuals are complete abstainers (no alcohol or drugs). In contrast, among the "self-changers" who did not attend treatment or self-help groups, the most common self-definition was used to have an alcohol or drug problem but don't any more , half of whom believe that recovery is abstinence while half do not, and only one-third are abstainers. Findings are of public health relevance, as it is estimated that among American adults alone, 10% report having had alcohol or drug problems but no longer do (The New York State Office of Alcoholism and Substance Abuse Services (OASAS), 2012). In line with the central concepts of social representation theory, people's pathways to recovery have a strong effect on how they define themselves and their behaviors and beliefs, but it is not universal.

Background: Recommended screening and brief intervention (SBI) for alcohol use during pregnancy is impeded by high patient loads and limited resources in public health settings. We evaluated the feasibility, acceptability and validity of a new self-administered, single-session, bilingual, computerized Screening and Brief Intervention (SBI) program for alcohol and sugar sweetened beverage (SSB) use in pregnancy., Methods: We developed and tested the computerized SBI program at a public health clinic with 290 pregnant women. Feasibility, acceptability, and validity measures were included in the program which had several modules, including those on demographics, health and beverage use. Time to complete the program and user experience items were used to determine program feasibility and acceptability. Validity analyses compared proportions of prenatal alcohol use identified by the program versus in-person screening by clinic staff., Results: Most program users (87%, n = 251) completed the entire program; 91% (n = 263) completed the key screening and brief intervention modules. Most users also completed the program in ten to fifteen minutes. Program users reported that the program was easy to use (97%), they learned something new (88%), and that they would share what they learned with others (83%) and with their doctors or clinic staff (76%). Program acceptability did not differ by age, education, or type of beverage intervention received. The program identified alcohol use in pregnancy among 21% of users, a higher rate than the 13% (p < .01) found via screening by clinic staff., Conclusions: Computerized Screening and Brief Intervention for alcohol and SSB use in public health clinics is feasible and acceptable to English and Spanish speaking pregnant women and can efficiently identify prenatal alcohol use.

Objective: Although recovery increasingly guides substance use disorder services and policy, definitions of recovery continue to lack specificity, thereby hindering measure development and research. The goal of this study was to move the substance use disorders field beyond broad definitions by empirically identifying the domains and specific elements of recovery as experienced by persons in recovery from diverse pathways., Method: An Internet-based survey was completed by 9,341 individuals (54% female) who self-identified as being in recovery, recovered, in medication-assisted recovery, or as having had a problem with alcohol or drugs (but no longer do). Respondents were recruited via extensive outreach with treatment and recovery organizations, electronic media, and self-help groups. The survey included 47 recovery elements developed through qualitative work followed by an iterative reduction process. Exploratory and confirmatory factor analyses were conducted using split-half samples, followed by sensitivity analyses for key sample groupings., Results: Four recovery domains with 35 recovery elements emerged: abstinence in recovery, essentials of recovery, enriched recovery, and spirituality of recovery. The four-factor structure was robust regardless of length of recovery, 12-step or treatment exposure, and current substance use status. Four uncommon elements did not load on any factor but are presented to indicate the diversity of definitions., Conclusions: Our empirical findings offer specific items that can be used in evaluating recovery-oriented systems of care. Researchers studying recovery should include measures that extend beyond substance use and encompass elements such as those examined here--e.g., self-care, concern for others, personal growth, and developing ways of being that sustain change in substance use.

Background: Research on alcohol consumption during pregnancy and miscarriage spans over three decades, yet the relationship is still not well-understood., Objectives: To assess the relationship between volume and type of alcohol consumed during pregnancy in relation to miscarriage., Methods: We utilized data from a population-based cohort study of pregnant women (n = 1061) of which 172 (16%) women had a miscarriage. Upon study entry, participants were asked about their alcohol consumption during pregnancy. Based on the average number of drinks per week, women were categorized into one of three categories: four or more drinks per week (n = 32, 3%), less than four drinks per week (n = 403, 38%), and no alcohol intake (n = 626, 59%). In addition, women were categorized by the type of alcohol beverage they consumed: beer only (n = 47, 4%), spirits only (n = 56, 5%), wine only (n = 160, 15%), or a combination of two or more types of alcohol (n = 172, 16%)., Results: A significant increased risk of miscarriage (adjusted hazard ratio (aHR): 2.65; 95% confidence interval (CI): 1.38, 5.10) was found for women who drank four or more drinks a week. Our findings also suggest the relationship between alcohol intake during pregnancy and miscarriage is strongest for miscarriage occurring prior to 10 weeks of gestation. In addition, women who drank only spirits had more than a two-fold increased risk of miscarriage compared to women who abstained (aHR: 2.24; 95% CI: 1.32, 3.81). Conclusions/Importance: Future research assessing the factors that may contribute to an increased risk of miscarriage should consider the type of alcohol consumed.

Background and Objectives: Despite Al-Anon's widespread availability and use, knowledge is lacking about the drinkers in attendees' lives. We filled this gap by describing and comparing Al-Anon newcomers' and members' reports about their "main drinker" (main person prompting initial attendance)., Methods: Al-Anon's World Service Office mailed a random sample of groups, yielding completed surveys from newcomers (N = 362) and stable members (N = 265)., Results: Newcomers' and members' drinkers generally were comparable. They had known their drinker for an average of 22 years and been concerned about his or her's drinking for 9 years; about 50% had daily contact with the drinker. Most reported negative relationship aspects (drinker gets on your nerves; you disagree about important things). Newcomers had more concern about the drinker's alcohol use than members did, and were more likely to report their drinkers' driving under the influence. Drinkers' most frequent problem due to drinking was family arguments, and most common source of help was 12-step groups, with lower rates among drinkers of newcomers. Concerns spurring initial Al-Anon attendance were the drinker's poor quality of life, relationships, and psychological status; goals for initial attendance reflected these concerns., Discussion and Conclusions: The drinker's alcohol use was of less concern in prompting initial Al-Anon attendance, and, accordingly, the drinker's reduced drinking was a less frequently endorsed goal of attendance., Scientific Significance: Family treatments for substance use problems might expand interventions and outcome domains beyond abstinence and relationship satisfaction to include the drinker's quality of life and psychological symptoms and in turn relieve concerns of family members., (© American Academy of Addiction Psychiatry.)

Objective: The purpose of this study was to examine the relations between drinking (mean quantity and heavy drinking patterns) and alcohol use disorders (AUDs) in the U.S. general population., Method: Data from three telephone National Alcohol Surveys (in 2000, 2005, and 2010) were pooled, with separate analyses for men and women restricted to current drinkers (ns = 5,922 men, 6,270 women). Predictors were 12-month volume (mean drinks per day), rates of heavy drinking (5+/4+ drinks in a day for men/women), and very heavy drinking (8+, 12+, and 24+ drinks in a day). Outcomes were negative alcohol-related consequences constituting abuse (1+ of 4 DSM-IV-based domains assessed by 13 items) and alcohol dependence (symptoms in 3+ of 7 DSM-IV-based domains), together taken to indicate an AUD. Segmentation analyses were used to model risks of problem outcomes from drinking patterns separately by gender., Results: In the general population, men and women who consumed ≤1 drink/day on average with no heavy drinking days did not incur substantial risks of an AUD (<10%). Men who drank from 1 to 2 drinks/day on average but never 5+ incurred a 16% risk of reporting an AUD (3.5% alcohol dependence). At higher volumes, men and women who indicated higher rates of drinking larger amounts per day and/or involving 8+ and 12+ drinks/day (and even 24+ drinks/day for men) showed much higher risks of experiencing AUDs., Conclusions: The findings provide quantitative guidance for primary care practitioners who wish to make population-based recommendations to patients who might benefit by reducing both overall intake and amounts per occasion in an effort to lower their risks of developing AUDs.

Objective: Empirical knowledge is lacking about Al-Anon Family Groups (Al-Anon), the most widely used form of help by people concerned about another's drinking, partly because conducting research on 12-step groups is challenging. Our purpose was to describe a new method of obtaining survey data from 12-step group attendees and to examine influences on initial Al-Anon attendance and attendees' recent life contexts and functioning., Method: Al-Anon's World Service Office sent a mailing to a random sample of groups, which subsequently yielded surveys from newcomers (n = 359) and stable members (n = 264)., Results: Reasons for groups' nonparticipation included having infrequent newcomers and the study being seen as either contrary to the 12 Traditions or too uncomfortable for newcomers. Main concerns prompting initial Al-Anon attendance were problems with overall quality of life and with the Al-Anon trigger (a significant drinking individual), and being stressed and angry. Goals for Al-Anon attendance were related to the following concerns: better quality of life, fewer trigger-related problems, and less stress. Members reported better functioning in some of these domains (quality of life, relationship with the trigger) but did not differ from newcomers on physical and psychological health. Newcomers were more likely to have recently drunk alcohol and to have obtained treatment for their own substance misuse problems., Conclusions: This method of collecting data from 12-step group attendees yielded valid data and also was seen by many in Al-Anon as consistent with the Traditions. Both newcomers and members had aimed to improve their overall quality of life and well-being through Al-Anon, and, indeed, members were more satisfied with their quality of life than were newcomers.

Aims: Investigators of the COMBINE (Combining Medications and Behavioral Interventions for Alcoholism) study examined whether combining medications with a behavioral intervention would improve outcomes over monotherapies. Unexpectedly, the combination did not offer any advantage over either treatment alone. This study aimed to explain the lack of incremental benefit offered by the combination over either monotherapy by assessing the role of cravings as a treatment mediator and moderator., Design: Secondary mediation and moderation analyses of COMBINE study data., Setting: Eleven United States academic sites., Participants: A total of 863 patients randomized to one of four treatment groups: naltrexone (100 mg/day; n = 209), the combined behavioral intervention (CBI, n = 236), naltrexone and CBI combined (n = 213) and placebo naltrexone (n = 205)., Measurements: Percentage of days abstinent (PDA) measured between 13 and 16 weeks post-baseline. Cravings, the potential mediator/moderator, were measured at baseline, weeks 4 and 12 using the Obsessive-Compulsive Drinking Scale., Findings: Compared with placebo, naltrexone, CBI and the combination all increased PDA by an additional 6-10 percentage points for those with high cravings (P < 0.05 for all three treatment groups). None had significant effects on PDA for those with low cravings. The effects of all three treatments were mediated at least partially by cravings; craving reduction explained 48-53% of treatment effects (P < 0.05 for all three treatment groups). Furthermore, naltrexone appeared to reduce cravings at 4 weeks, while CBI did not reduce cravings until 12 weeks., Conclusions: The Combining Medications and Behavioral Interventions for Alcoholism (COMBINE) naltrexone + CBI combination may not be more beneficial than either monotherapy because craving reduction is a common mechanism of both., (© 2013 Society for the Study of Addiction.)

A trial of "Making Alcoholics Anonymous Easier" (MAAEZ), a group-format 12-step facilitation program, showed significantly higher odds of past 30-day abstinence after 12 months among those who had been treated in MAAEZ compared to usual care, especially for clients with high prior AA/NA/CA meeting attendance (>90 prior meetings; OR = 2.94, p = .02). We examined whether MAAEZ effects for this group were mediated by social support for sobriety and comfort with the 12-step fellowship. Among those with high prior AA/NA/CA attendance, we performed tests of multiple mediation to estimate MAAEZ effects attributable to the combined effect of social network support for sobriety, comfort being at AA/NA/CA meetings, and comfort speaking at AA/NA/CA meetings. To gain some understanding of sustaining these behaviors, we also examined each potential mediating variable measured both prior to, and concurrent with, 12-month outcomes. Having support for sobriety at 6 months emerged as a mediator of 12-month MAAEZ effects, when controlling for comfort being and speaking at AA/NA/CA meetings at 6 months. The effect remained when controlling for mediator values at 12 months, and explained 44% of the MAAEZ effect. Results highlight the value of studying specific, modifiable 12-step activities, and demonstrate the importance of exploring subgroups to determine behaviors and attitudes to target for optimal treatment. For example, increasing support for sobriety among those with high prior AA/NA/CA attendance may be especially pertinent., (2013 APA, all rights reserved)

This study grouped treatment-seeking individuals (n = 1825) by common patterns of 12-step attendance using 5 waves of data (75% interviewed Year 9) to isolate unique characteristics and use-related outcomes distinguishing each class profile. The "high" class reported the highest attendance and abstention. The "descending" class reported high baseline alcohol severity, long treatment episodes, and high initial attendance and abstinence, but by Year 5, their attendance and abstinence dropped. The "early-drop" class, which started with high attendance and abstinence but with low problem severity, reported no attendance after Year 1. The "rising" class, with fairly high alcohol and psychiatric severity throughout, reported initially low attendance, followed by increasing attendance paralleling their abstention. Last, the "low" and "no" classes, which reported low problem severity and very low/no attendance, had the lowest abstention. Female gender and high alcohol severity predicted attendance all years. Consistent with a sustained benefit for 12-step exposure, abstinence patterns aligned much like attendance profiles., (Copyright © 2012 Elsevier Inc. All rights reserved.)

A recent trial (n=508) of "Making Alcoholics Anonymous Easier" (MAAEZ), a group-format 12-step facilitation program, showed that MAAEZ participants had increased odds of abstinence (OR=1.58; p=0.063). Effects were especially marked in several subgroups, including those with more prior AA/NA/CA exposure, and those with severe psychiatric problems. This paper examines whether the effects of MAAEZ were explained by higher engagement in particular Alcoholics Anonymous (AA) and other 12-step organization activities. Mediation analyses were performed, estimating MAAEZ effects attributable to AA/NA/CA meeting attendance, overall AA/NA/CA involvement, having a sponsor, and engaging in 12-step service. The only variable that appeared to mediate MAAEZ effects in the sample overall was doing service at either 6 months or at both 6 and 12 months. Among those with high prior AA/NA/CA attendance, both having a sponsor and doing service emerged as mediators, with having a sponsor explaining approximately 25% of the MAAEZ effect. Doing service also partially explained the MAAEZ effect among those with high psychiatric severity. Results highlight the value of studying specific AA/NA/CA activities as mediators of treatment effects, and demonstrate the importance of exploring subgroups when trying to understand treatment mechanisms. Findings also suggest that treatment programs should emphasize specific activities for particular clients. For example, individuals may have attended many AA/NA/CA meetings, but never known how to ask for a sponsor or get involved in service; doing service may represent a non-threatening way of connecting with 12-step members for clients with psychiatric problems such as social anxiety., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objective: To determine whether multivitamin supplements modify the relationship between alcohol consumption during pregnancy and the risk of miscarriage., Study Design: We used data from a population-based cohort study of pregnant women (n=1061; response rate=39%). Participants were asked about their alcohol consumption and vitamin intake during pregnancy., Results: Among multivitamin nonusers, women who drank alcohol during their pregnancy were more likely to have a miscarriage compared with women who abstained (adjusted hazard ratio, 1.67; 95% confidence interval, 1.04-2.69). However, among multivitamin users, there was no difference in the risk of miscarriage between alcohol consumers and abstainers. Results suggest the volume of alcohol as well as the timing of multivitamin supplementation may also be important., Conclusion: Our findings suggest that a woman of childbearing years might decrease her risk of miscarriage associated with alcohol intake by taking multivitamin supplements. However, our findings should be interpreted with caution and future research replicating these findings is necessary.

Although many members of Alcoholics Anonymous (AA) are introduced to AA during treatment, the relationship between treatment and AA attendance over time is unknown. This paper describes four latent classes of AA attendance among 586 dependent alcoholics interviewed by telephone 1, 3, 5 and 7 years after baseline, and models the relationship between treatment exposure and AA attendance in each class. There was a low AA group (averaging fewer than 5 meetings at most follow-ups), a medium AA group (about 50 meetings a year at each follow-up), a descending AA group (about 150 meetings year 1, then decreasing steeply), and a high AA group (about 200 meetings at 1 year, then decreasing gradually by year 7). Declines in meeting attendance were not always accompanied by decreases in abstinence. After accounting for the effect of time on AA attendance (i.e., the "ups-and-downs" that occur over time), treatment exposure was minimally related to AA attendance in all but the descending AA group, where it was negatively associated (p<0.001). Considering AA patterns over time highlights a different role for treatment in AA attendance than what is gleaned from analyses at single timepoints.

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.

Background: Drop-out from 12-step groups is notoriously high, yet the field lacks strong models and scales for addressing this problem. We aim to determine whether the theory of planned behavior (TPB) can be applied to 12-step involvement, and to develop and validate a scale of 12-step readiness based on that theory: the Alcoholics Anonymous Intention Measure (AAIM)., Method: Data were from a longitudinal trial of a manual-guided 12-step facilitation intervention called Making AA Easier (MAAEZ) involving two treatment programs in California (N=508). Participants completed surveys at baseline, 7 weeks, 6 months, and 12 months. Surveys included the preliminary AAIM, a 12-step involvement measure, other readiness measures, and substance use outcomes., Results: The final, 17-item AAIM measured Attitude (5-item alpha's=.75-.83), Subjective Norm (4-item alpha's=.56-.81), Perceived Control (5-item alpha's=.78-.85), and Intention (3-item alpha's=.80-.95) regarding attendance at 12-step groups. Components were correlated with each other and other readiness measures as expected, supporting the AAIM's validity. Scale components predicted 31% of the variance in Intention to attend 12-step groups at 6 months and 41% of the variance in 12-step involvement at 12 months. Social factors were among the strongest predictors of 12-step involvement. Results did not support the expectancy-value formulation of the TPB, as unweighted (vs. weighted) belief items performed optimally., Conclusions: Results generally support the TPB as a model of 12-step involvement and suggest specific targets for 12-step facilitation interventions within attitude, norm, and control components. Findings also support the AAIM as a tool for identifying drop-out risks and tailoring individual interventions.

Background: The effectiveness of Alcoholics Anonymous (AA) is difficult to establish. Observational studies consistently find strong dose-response relationships between AA meeting attendance and abstinence, and the only experimental studies favoring AA have been of 12-step facilitation treatment rather than of AA per se. Pending future randomized trials, this paper uses propensity score (PS) method to address the selection bias that potentially confounds the effect of AA in observational studies., Method: The study followed a treatment sample for 1 year to assess post-treatment AA attendance and abstinence (n=569). Propensity scores were constructed based on known confounders including motivation, problem severity, and prior help-seeking. AA attendance during the 12-month follow-up period was studied as a predictor of alcohol abstinence for 30 days prior to the follow-up interview. PS stratification and PS matching techniques were used to adjust for the self-select bias associated with respondents' propensity to attend AA., Results: The overall advantage in abstinence initially observed narrowed when adjusted. The odds ratio associated with AA attendance reduced from 3.6 to 3.0 after PS stratification and 2.6 after PS matching to AA-attenders. Support for AA effectiveness was strengthened in the quintile with lower propensity scores and when AA-nonattenders were matched as the target group, but was weakened among those in the higher PS quintiles and when matching to AA-attenders., Discussion: These results confirm the robustness of AA effectiveness overall, because the results for higher abstinence associated with AA attendance following propensity score adjustment remained significant, and the reduction in the magnitude of AA's effect was moderate. However, the effect modification by propensity scores in both PS stratification and PS matching approaches seems to suggest that AA may be most helpful, or matter more, for those with a lower propensity to attend AA. Conversely, for those with a high propensity to go to AA (operationalized as higher motivation, greater problem severity, more prior AA and treatment exposure, etc.), attending AA may not make as much of a difference. It will be important that future studies replicate our results, as this is the first paper to use propensity score adjustment in this context.

Aims: Twelve-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., Design: We 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., Measures: Measures at follow-up included alcohol and drug use, 12-Step affiliation, social support and frequency of religious service attendance., Findings: At 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., Conclusions: The 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.

This clinical trial compared two brief alcohol use interventions in prenatal clinics: Early Start (ES), a substance-abuse screening and treatment program integrated with prenatal care focused on abstention (n=298), and Early Start Plus (ESP), adding a computerized drink-size assessment tool and intervention focused on drinking less (n=266). Controls were untreated alcohol users (n=344). Controls had higher adverse neonatal and maternal outcome rates. Findings favored ESP for preterm labor and ES for low birth weight. No differences between ES and ESP were statistically significant. ESP provides clinicians with an innovative assessment tool that creates open dialogue about drinking during pregnancy.

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.

This longitudinal health services study (N = 733) (1) examines the impact of services received on 6-month outcomes, and (2) compares day-hospital to residential programs on services received. Services were measured at 2, 4, and 8 weeks postbaseline using a version of the Treatment Services Review. Higher odds of total sobriety at 6 months were associated with greater participation in (a) extracurricular (but not curricular) 12-step meetings, (b) sober recreational events, and (c) educational sessions. Program effects also emerged. Unexpectedly, extracurricular 12-step meeting attendance and the odds of having a sponsor were lower among residential (vs. day hospital) participants through 4 weeks, despite higher participation in curricular 12-step meetings among residential participants at 2 weeks. Still, residential participants reported higher involvement in sober recreation and informal peer socialization across most analyses. Findings suggest that residential and day-hospital programs might maximize outcomes by facilitating optional 12-step involvement and sober recreation, respectively.

Objective: Evidence suggests that people misjudge the size of their drinks, calling into question the validity of data from surveys and screening instruments assessing alcohol quantity in terms of standard drinks. This article studied the validity of photographs of glasses to assess drink size., Method: In a U.S. national sample of 323 drinkers, respondents were mailed a measuring beaker and a set of photographs of wine, beer, and other drinking glasses for use in a subsequent telephone survey. In the interview, they were asked to pick the glass most similar to what they use at home and to identify the letter associated with their usual pour level. Then, a protocol where subjects measured the actual number of ounces in their typical drink, by pouring water into their usual glass and measuring this volume using the measuring beaker, gave a direct measure of home drink volume. We compared drink sizes using the two approaches., Results: Photographs worked well for certain groups, including women, young people, and nonwhites (for wine) and whites (for beer). The greatest magnitude of error arising from the use of photographs was for wine drinks among those age 50 and older, those with a 4-year degree, frequent 5+ drinkers in general, and heavy-volume wine drinkers. Average drink size based on the most popular wine and beer glasses in the photographs were 0.62 oz (18 ml) and 1.62 oz (48 ml) larger than beaker pours, respectively. Error between actual drinks and photographs was especially high for a large balloon-shaped wine glass, chosen by only 3% of wine drinkers., Conclusions: Whenever possible, researchers and clinicians should incorporate protocols that allow for some type of direct measurement using the actual vessels from home. When this is not viable, photographs represent a solution that is practical, shows promise for beer and wine drinks, and is relevant to any drinking context.

Background: Patient placement criteria developed by the American Society of Addiction Medicine (ASAM) have identified a need for low-intensity residential treatment as an alternative to day hospital for patients with higher levels of severity. A recent clinical trial found similar outcomes at social model residential treatment and clinically-oriented day hospital programs, but did not report on costs., Aims: This paper addresses whether the similar outcomes in the recent trial were delivered with comparable costs, overall and within gender and ethnicity stratum., Method: This paper reports on clients not at environmental risk who participated in a randomized trial conducted in three metropolitan areas served by a large pre-paid health plan. Cost data were collected using the Drug Abuse Treatment Cost Analysis Program (DATCAP). Costs per episode were calculated by multiplying DATCAP-derived program-specific costs by each client's length of stay. Differences in length of stay, and in per-episode costs, were compared between residential and day hospital subjects., Results: Lengths of stay at residential treatment were significantly longer than at day hospital, in the sample overall and in disaggregated analyses. This difference was especially marked among non-Whites. The average cost per week was USD 575 per week at day hospital, versus USD 370 per week at the residential programs. However, because of the longer stays in residential, per-episode costs were significantly higher in the sample overall and among non-Whites (and marginally higher for men)., Discussion: These cost results must be considered in light of the null findings comparing outcomes between subjects randomized to residential versus day hospital programs. The longer stays in the sample overall and for non-White clients at residential programs came at higher costs but did not lead to better rates of abstinence. The short stays in day hospital among non-Whites call into question the attractiveness of day hospital for minority clients., Conclusion: Outcomes and costs at residential versus day hospital programs were similar for women and for Whites. For non-Whites, and marginally for men, a preference for residential care would appear to come at a higher cost., Implications for Health Care Provision and Use: Lengths of stay in residential treatment were significantly longer than in day hospital, but costs per week were lower. Women and Whites appear to be equally well-served in residential and day hospital programs, with no significant cost differential. Provision of residential treatment for non-Whites may be more costly than day hospital, because their residential stays are likely to be 3 times longer than they would be if treated in day hospital. For men, residential care will be marginally more costly. IMPLICATIONS FOR HEALTH POLICY FORMULATION: Residential treatment appears to represent a cost-effective alternative to day hospital for female and White clients with severe alcohol and drug problems who are not at environmental risk., Implications for Further Research: The much shorter stays in day hospital than at residential among non-Whites highlight the need for research to better understand how to best meet the needs and preferences of non-White clients when considering both costs and outcomes.

This study adds to a growing literature showing that definitions for "standard drinks" are often difficult to conceptualize and that people often underestimate their actual drink sizes. As part of an intervention aimed at reducing negative neonatal and maternal outcomes, insured at-risk women were asked to identify the vessels from which they drank each of 6 beverages (n=266). We calculated differences between their actual and standard drink sizes. Additionally, differences were compared to those reported in an earlier study of uninsured inner city minority women that used identical vessels methodology. Over half of the spirits, fortified wine and malt liquor drinkers underestimated the actual number of ounces their drinks contained. Most spirits drinkers (90%) and approximately three-quarters of the wine and malt liquor drinkers drank larger-than-standard drink sizes, with the median drink size 1.5 to 2.0 times larger than the standard size for those beverages. Heavier drinkers (>/=3 drinks per sitting) were more likely than lighter drinkers to underestimate their drink sizes. Findings were similar to those in the previous study using identical drink size measurements. Accurately assessing true drink sizes is underscored when the social, health and epidemiologic consequences associated with miscalculation are considered.

This chapter draws on AA membership surveys, US general population surveys, and longitudinal treatment data to compile profiles of those ever exposed to AA in their lifetime, those who no longer report AA meeting attendance, and those who attend AA meetings currently. We consider demographics (gender, age, ethnicity, marital status), receipt of specialty treatment, and short- and long-term abstinence rates among these AA exposure groups. Results suggest stability in the representation of women and minorities among the AA membership, but a decline among youth. Fully one-half of those completing AA's most recent membership survey reported that they had been abstinent for more than 5 years. Those receiving specialty treatment any given year are likely to report AA exposure that year. Disengagement from AA does not appear to necessarily translate to loss of abstinence among those with initial high levels of AA exposure, but long-term abstinence is more likely among those with continued engagement.