1. Evidence for twelve step facilitation in the medical literature Jonathan Chick HLO’s meeting, York, March 2014

2. How to show that AA is effective? Health commissioners expect positive results of RCTs (randomised, controlled, studies) - “perhaps the people who do well in AA would have done well anyhow because they are ‘well motivated’”

3. Evidence for AA (1) True randomised controlled study impossible, but: Many follow-up studies show that stable recovery is associated with regular attendance at AA / NA

4. Enhanced friendship networks and active coping mediate the effect of self-help groups on substance abuse –2,337 male veterans treated for substance abuse –The majority of participants became involved in self-help groups after inpatient treatment –group involvement predicted reduced substance use at 1-year follow-up –enhanced friendship networks and increased active coping responses appeared to mediate these effects Humphreys et al Humphreys et al. 1999 Ann Behav Med21:54-60

5. Attendance at Alcoholics Anonymous meetings after inpatient treatment is related to better outcomes; a 6-month follow-up study. (Gossop et al National Addiction Centre, Institute of Psychiatry, London ) Participants interviewed at admission (within 5 days of entry), and (80%) 6 months following departure. N= 150 patients in an inpatient alcohol treatment programme who met ICD-10 criteria for alcohol dependence. RESULTS: Those who attended AA on a weekly or more frequent basis after treatment reported greater reductions in alcohol consumption and more abstinent days. This relationship was sustained after controlling for potential confounding variables. Frequent AA attendance related only to improved drinking outcomes. Despite the improved outcomes, many of the sample had alcohol and psychiatric problems at follow-up.

6. Correlates of Recovery from Alcohol Dependence: A Prospective Study Over a 3-Year Follow-Up Interval Dawson et al. Online Alc Clin Exp Res: 6 FEB 2012 Wave 1: Alcohol dependence (n = 1,172) Wave 2: Abstinent recovery significantly associated with Black/Asian/Hispanic race/ethnicity, children <1 year of age in the household at baseline, attending religious services greater than or equal to weekly at follow-up, and having initiated help-seeking that comprised/included 12-step participation within <3 years prior to baseline.

7. Evidence for AA (2) RCTs of ‘Facilitation’ by healthcare professionals

8. Project MATCH Research group Addiction 1997;92:1671-98 Out-patients N=952 Aftercare following in-patient stay N=774 Random allocation to either: 12 sessions cognitive behavioral therapy- CBT or 12 sessions of twelve-step facilitation- TSF or 4 sessions of motivational enhancement therapy - MET

9. PROJECT MATCH: 1 year outcome Time to First Drink, and Time to 3 Successive Heavy Drinking Days, better in TSF than CBT or MET Highly dependent did best in TSF (low dependence better in CBT) At 3 years, still slight advantage on some measures to TSF (Only 40% of TSF patients regularly attended AA)

10. Randomised Controlled trial of intensive referral to 12 step self help groups: Timko and DeBenedetti, Drug Alc Depend 2007; 90:270-9 N=345 ; 96% had previous addiction treatment. Random assignment to a standard referral or an intensive referral-to-self-help condition Intensive referral: counselors linked patients to 12-step volunteers and checked on meeting attendance. One-year follow-up (93%). RESULTS: Compared with patients who received standard referral, patients who received intensive referral were more likely to attend and be involved with 12-step groups during both the first and second six-month follow-up periods, and improved more on alcohol and drug use outcomes over the year. During both follow-up periods, patients in intensive referral were more likely to attend at least one meeting per week (70% versus 61%, p=.049) and had higher involvement (mean=4.9 versus 3.7, p=.021) and abstinence rates (51% versus 41%, p=.048). Twelve-step involvement mediated the association between referral condition and alcohol and drug outcomes, and was associated with better outcomes above and beyond group attendance

11. Dual diagnosis (i.e. addiction + serious mental illness) Bogenschutz Bogenschutz et al J Subst Abuse Treat.J Subst Abuse Treat. 2014 46:403-11. “12-step facilitation for the dual diagnosed: A randomized clinical trial” No advantage in terms of alcohol/drug use (but more meetings -> better outcomes)

12. Twelve Step Facilitation (TSF) in cocaine-dependent individuals maintained on methadone: a randomized placebo-controlled trial Carroll et al. Carroll et al Cocaine used reduced with TSF Drug Alcohol Depend.Drug Alcohol Depend. 2012 126:224-31

13. TSF as effective in cocaine addiction as as giving vouchers for clear urines cocaine (up to 12 months) Contingency management with community reinforcement approach or twelve-step facilitation drug counseling for cocaine dependent pregnant women or women with young children. Schottenfeld et alSchottenfeld Drug Alcohol Depend. 2011 Oct 1;118(1):48-55.Drug Alcohol Depend.

14. J Subst Abuse Treat.J Subst Abuse Treat. 2009 Oct;37(3):228-39. Epub 2009 Apr 1. Effectiveness of Making Alcoholics Anonymous Easier: a group format 12-step facilitation approach. Kaskutas LA, Subbaraman MS, Witbrodt J, Zemore SE. Kaskutas LASubbaraman MSWitbrodt JZemore SE 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.

15. Social relationships predict not just mental health and wellbeing but also ‘hard’ impacts like mortality 15 UNCLASSIFIED LGID: Wellbeing - why bother? Meta analysis: comparative odds of decreased mortality Source: Holt-Lundstad et al 2010 social relationships have as great an impact as smoking cessation, and more than physical activity and issues to address obesity

16. NICE 2011 (National Institute for Health and Clinical Excellence) Diagnosis, assessment and management of harmful drinking and alcohol dependence “For all people seeking help for alcohol misuse: give information on the value and availability of community support networks and self-help groups (for example, Alcoholics Anonymous or SMART Recovery) and help them to participate in community support networks and self-help groups by encouraging them to go to meetings and arranging support so that they can attend ”