John M. Talmadge, M.D.

A Blog Covering Many Topics

CASA Report on Addictions

CASA, the Center for Alcohol and Substance Abuse at Columbia University, is acknowledged as the leader in research and education in alcoholism and other addictions. CASA reports that 40 million Americans age 12 and over meet the clinical criteria for addiction involving nicotine, alcohol or other drugs. That is more than the number of people with heart conditions, diabetes or cancer. Meanwhile, another 80 million Americans fall into the category of risky substance users, defined as those who are not addicted, but use tobacco, alcohol and other drugs in ways that threaten public health and safety.

CASA Columbia’s work for this report involved:
• A review of more than 7,000 publications
• Analyses of 5 national data sets
• Interviews with and suggestions from 176 leading experts in a broad range of fields relevant to the report
• Focus groups and a national general population survey of 1,303 adults about their attitudes and beliefs related to addiction and its treatment
• Two New York State surveys of addiction treatment providers
• An online survey of 1,142 members of professional associations involved in addiction care
• An online survey of 360 individuals with a history of addiction
• Analyses of state and federal governments’ and professional associations’ licensing and certification requirements for treatment providers
• A case study of addiction treatment in New York State and New York City 

This 5-year study found that, despite the prevalence of addiction, the enormity of its consequences, the availability of effective solutions and the evidence that addiction is a disease, both screening and early intervention for risky substance use are rare, and only about 1 in 10 people with addiction involving alcohol or drugs other than nicotine receive any form of treatment. 

Of those who do receive treatment, few receive anything that approximates evidence-based care. This compares with 70% to 80% of people with such diseases as high blood pressure and diabetes who do receive treatment. This report exposes the fact that most medical professionals who should be providing addiction treatment are not sufficiently trained to diagnose or treat the disease, and most of those providing addiction care are not medical professionals and are not equipped with the knowledge, skills or credentials necessary to provide the full range of effective treatments. Misunderstandings about the nature of addiction and the best ways to address it, as well as the disconnection of addiction medicine from mainstream medical practice, have undermined effective addiction treatment.

CASA Recommendations: The time has come for addiction medicine to be fully integrated into health care systems and medical practice. Health care providers, especially physicians, are our front line in disease prevention and treatment. They must understand the risk factors for addiction, screen for risky substance use and intervene when needed, and diagnose, treat and manage addiction just as they do all other diseases.

Other health care providers, including nurse practitioners, physician assistants, psychologists and social workers, are critical parts of the solution as well. We need national, evidence-based standards that stipulate who may provide addiction treatment, and core competencies for all health care providers integrated into their education and licensing requirements. We must regulate addiction treatment facilities and programs as health care providers and hold them accountable for treatment consistent with medical standards and proven practices.

Do 12-Step Programs Work?

Do mutual help organizations like Alcoholics Anonymous really work? Last year, The Carlat Report on Addiction Treatment reviewed the research on AA and reported positive findings. I've summarized that report and included the references here. AA and other 12 Step programs provide many of the elements found in formal treatment. More importantly, the recovering fellowship creates a framework for support over the long term, helping individuals stay sober longer, have fewer drinking days, and have shorter periods of relapse. Twelve Step Facilitation (TSF) has been found as effective as cognitive behavioral therapy in addressing alcohol-related issues.

Since the 1930's when Bill W. and Dr. Bob started Alcoholics Anonymous (AA) the fellowship has grown to over two million members. Meeting in rented rooms, school halls, hospitals, and the storied church basement, AA and similar 12-step organizations (eg, Narcotics Anonymous [NA]) remain the most commonly sought sources of help for substance-related problems in the United States (Substance Abuse and Mental Health Services Administration. Results from the 2007 National Survey on Drug Use and Health: National Findings. Rockville, MD: Office of Applied Studies; 2008).

Research has shown that attending AA, either alone or during and following professional treatment, enhances outcomes. One naturalistic study, for example, followed 466 previously untreated individuals with problem drinking for eight years. Participants self-selected into one of four groups: no treatment, AA alone, formal treatment alone, and formal treatment plus AA. Those who received some sort of help—AA, formal treatment, or both—had higher rates of abstinence at all time points. At eight years, 26% of patients in the no treatment group were abstinent from alcohol compared to 49% who received AA alone, 46% who received formal treatment alone, and 58% who received the combination of treatment plus AA (Timko C et al, J Stud Alcohol 2000;61(4):529–540).

A systematic Cochrane review of the best scientific studies on AA and TSF found that they were as effective as any of the interventions to which they were compared for some factors, such as retention in treatment, but found that no studies unequivocally proved AA and TSF were superior to other treatments (Ferri M et al, Cochrane Database Syst Rev 2006;(3):CD005032).

Other studies have found a linear dose-response relationship between AA attendance and favorable drinking outcomes (Kaskutas LA, J Addict Dis 2009;28(2):145–157). Attending one meeting per week, on average, appears to be the minimum threshold to realize benefit and increasing meeting frequency is associated with progressively greater rates of abstinence. In addition, research has shown that women engage with AA as much as men, become more involved with the 12 Steps, and derive similar benefit. In 1990, the Institute of Medicine called for more research on how AA works. Since then, research has revealed that AA aids recovery through multiple mechanisms, many of which are also activated by professional behavioral treatments (Kelly J et al, Addict Res Theory 2009:17(3):236–259).

Most consistently and strongly, AA appears to work by helping people make positive changes in their social networks (eg, by dropping heavy drinkers/drug users and increasing abstainers/low risk drinkers), and by enhancing coping skills and self-efficacy for abstinence when encountering high-risk social situations (see for example, Kelly JF et al, Drug Alcohol Depend 2011;114(2–3):119–126).

Among more severely addicted people, AA also appears to work by enhancing spiritual practices, reducing depression, and increasing individuals’ confidence in their ability to cope with negative emotion (Kelly JF et al, Addiction 2012;107(2)289–299). Thus, AA appears to work through diverse mechanisms and may work differently for different people. Stated another way: individuals may use AA differently, depending on their unique needs and challenges.

Research has shown that involvement in 12-step work can reduce the need for more costly treatments while simultaneously improving outcomes. A large multicenter study of over 1,700 patients found those treated in professional 12-step treatment went on to participate in community-based AA and NA meetings at a higher rate than those from professional cognitive behavioral therapy (CBT) programs, who relied more heavily on professional services. This translated into a two-year savings of over $8,000 per patient among 12-step treated patients, without compromising outcomes. In fact, those treated in the 12-step treatment programs had one-third higher rates of abstinence across follow-up (Humphreys K & Moos R, Clin Exp Res 2001;25(5):711–716; Humphreys & Moos, Alcohol Clin Exp Res 2007;31(1):64–68).

Project MATCH was a large randomized trial comparing three individually-delivered psychosocial treatments for alcohol use disorder—TSF, CBT, and Motivational Enhancement Therapy (MET)—that was funded by NIAAA. It included 1,726 patients from nine clinical sites across the US (Project Match Research Group, J Stud Alcohol 1997;58(1):7–29). TSF was found to be as effective as the more empirically supported CBT and MET interventions at reducing the quantity and frequency of alcohol use post-treatment and at one- and three-year follow-ups. Moreover, TSF was superior to CBT and MET at increasing rates of continuous abstinence, such that 24 percent of the outpatients in the TSF condition were continuously abstinent at one year after treatment, compared with 15 percent and 14 percent in CBT and MET, respectively (Tonigan JS et al,Participation and involvement in Alcoholics Anonymous. In: Babor TF & Del Boca FK, eds. Treatment Matching in Alcoholism. New York: Cambridge University Press;2003:184–204).

Abstinence rates at three years continued to favor TSF, with 36 percet reporting complete abstinence, compared with 24 percent in CBT, and 27 percent in MET (Cooney N et al. Clinical and scientific implications of Project MATCH. In: Babor TF & Del Boca FK, eds. Treatment Matching in Alcoholism. New York: Cambridge University Press; 2003:222–237).

In light of findings from several such RCTs that demonstrated the efficacy of TSF, this therapy was added to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-Based Practices and Programs (NREPP) in 2008.

The overwhelming majority of research has been conducted on AA. More research is needed on other MHOs, such as SMART Recovery, LifeRing, Celebrate Recovery, Women for Sobriety, Moderation Management, and others, so that more objective evidence is gathered on secular, religious, and non-abstinence-based AA alternatives (see the article "Alternatives to 12-Step Recovery" for more on these groups).