Helping Young Adults Step Up in Meetings & Step Down Use

An enhanced delivery of 12-step facilitation, which includes active referral to volunteers in the community and integration with outpatient substance use treatment may be particularly effective for helping young adults maintain sobriety from stimulants.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

Emerging adulthood (ages 18-29) has the highest prevalence of substance use disorders compared with other age groups. However, emerging adults pose unique challenges in terms of substance use treatment. Prior studies on groups facilitating involvement in 12-step mutual help organizations have found conflicting results as to whether these 12-step facilitation interventions are as effective as Cognitive Behavioral Therapy (CBT) or other treatment modalities for younger adults. This study tested a 12-step facilitation approach enhanced by active peer linkages to meetings, which might be more effective way to engage emerging adults in 12-step meetings.

HOW WAS THIS STUDY CONDUCTED?

DESIGN: Two group randomized treatment trial comparing treatment as usual (TAU) to TAU integrated with STAGE-12 (Stimulant Abuser Groups to Engage in 12 Step) over eight weeks of active substance use treatment with six-month follow-up. Each week, a STAGE-12 group and individual session replaces one hour per week of TAU over the eight weeks of active treatment. For five of the eight weeks, STAGE-12 participants attended a group session, and for three weeks they attended an individual session.

MORE ON STUDY METHODS

SETTING: Intensive Outpatient Programs at ten community treatment programs across the US

PARTICIPANTS: 450 adults with a stimulant use disorder (using DSM-IV criteria) enrolled at one of the community treatment programs in intensive outpatient treatment. Age was analyzed as a continuous variable although reported comparing emerging adults (ages 18-29) vs older participants.

MEASUREMENT: Primary substance use outcome is number of self-reported days of stimulant drug use; secondary outcome is number of days of non-stimulant drug/alcohol use. Other outcome variables include days of Twelve-Step Meeting attendance and a measure of active involvement in 12-step groups by self-report questionnaire.

WHAT DID THIS STUDY FIND?

Younger participants showed a greater response to a STAGE-12 intervention to increase 12-step participation than older participants to maintain stimulant abstinence: The 20 year old participants were more likely than the 50 year old participants to remain abstinent from stimulants when comparing Stimulant Abuser Groups to Engage in 12 Step (STAGE-12) to treatment as usual (Odds ratio 4.128 vs 2.939). In fact, although STAGE-12 has been previously shown to increase the odds of abstinence, by age 46 and above, there is no statistically significant effect of STAGE-12 over treatment as usual for these older participants.

Of note, the increased utility of STAGE-12 for younger participants only holds for participants who achieved abstinence at the beginning of the study who then had a higher probability of maintaining abstinence. For the group of younger participants who did not achieve abstinence at the beginning of the trial, they actually had higher rates of stimulant use in follow-up in the STAGE-12 arm vs treatment as usual (perhaps using more once they had violated abstinence).

The benefits of STAGE-12 participation are moderated by increased involvement in 12-step groups: Younger participants in STAGE-12 compared to treatment as usual had a greater odds of active participation in 12-step mutual help organizations activities, beyond meeting attendance, than older participants in STAGE-12 compared to treatment as usual. Interestingly, meeting attendance per se was not shown to be a moderator of the differential effect of STAGE-12, rather the involvement beyond meeting attendance was increased in younger vs older participants in STAGE-12 vs treatment as usual.

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

This study tests a 12-step facilitation approach that incorporates an intensive referral component that actively connects participants with a 12-step volunteer in the community who arranges to attend a meeting with them. While this study cannot speak directly to why the 12-step facilitation was more helpful for young adults, it seems most likely this active linkage component may explain the findings showing 12-step facilitation increased the odds of abstinence in emerging adults, a group which had not previously been shown to benefit as much from 12-step facilitation as opposed to other interventions.

Establishing a connection between the participants and attendees at 12-step meetings may be contributing to social network changes, which may be more challenging for emerging adults because, on average, they have more individuals that misuse alcohol and other drugs in their networks than older adults. However, those who ended up using during the study were not benefited by the addition of STAGE-12 and had in fact, worse outcomes than treatment as usual. This may be explained by the 12-step emphasis on abstinence such that once abstinence is breached, there may be less emphasis on controlled use (an either-or mentality), known as the abstinence violation effect.

LIMITATIONS

Outcomes were all measured using self-report thus decreasing the reliability of the data
This study was done across 10 sites which is a strength, but they did not control for site and the treatment as usual arm had variations from site to site with a minimum of shared components
The data is all presented post-statistical analysis (Odds or Rate ratios) with no presentation of the actual data for stimulant or other abstinence or relapse at the end of the study or at follow-up, making it hard to discern the actual effectiveness of the treatment as usual or the addition of the STAGE-12 intervention

BOTTOM LINE

For individuals & families seeking recovery: Incorporating 12-step facilitation interventions can further enhance recovery for individuals with stimulant use disorders like cocaine or methamphetamine, particularly in younger adults who have an abstinence goal.
For scientists: Introducing an active 12-step meeting linkage to 12-step facilitation approach may substantially increase its effectiveness for emerging adults, a group previously shown to not be as responsive to this intervention as older adults in the short-term.
For policy makers: In thinking about the differences that emerging adults present vs older adults, focusing on interventions that help them modify their social networks away from substance use may be particularly effective for this population. Creating social environments that discourage use, such as collegiate recovery programs, recovery social events such as concerts or weekend parties, may help young adults integrate recovery in a more meaningful way.
For treatment professionals and treatment systems: The 12-step facilitation model tested here (STAGE-12) with its referral component connecting participants to a new community, may be an effective way of further enhancing the effectiveness of substance use treatment and enhancing abstinence that can be integrated into existing treatment models.