Cost-Effectiveness of Home Visits in the Outpatient Treatment of Patients with Alcohol Dependence

The purpose of this study was to compare the cost-effectiveness of conventional outpatient treatment for alcoholic patients (CT) with this same conventional treatment plus home visits (HV), a new proposal for intervention within the Brazilian outpatient treatment system.

A cost-effectiveness evaluation alongside a 12-week randomized clinical trial was performed. We identified the resources utilized by each intervention, as well as the cost according to National Health System (SUS), Brazilian Medical Association (AMB) tables of fees, and others based on 2005 data. The incremental cost-effectiveness ratio (ICER) was estimated as the main outcome measure – abstinent cases at the end of treatment.

• There were 51.8% abstinent cases for HV and 43.1% for CT, a clinically relevant finding.
• Other outcome measures, such as quality of life, also showed significant improvements that favored HV.

The baseline scenario presented an ICER of USD 1,852. Sensitivity analysis showed an ICER of USD 689 (scenario favoring HV) and USD 2,334 (scenario favoring CT).

The HV treatment was found to be cost-effective according to the WHO Commission on Macroeconomics and Health.

Research; Edilaine Moraesa, Geraldo M. Camposa, Neliana B. Figliea, Ronaldo Laranjeiraa, Marcos B. Ferrazb. Eur Addict Res 2010;16:69-77 (DOI: 10.1159/000268107)

• See also
• Psychology Books
• 12 Steps and Post Traumatic Stress
• AA & NA Work for Teens Too
• Stools and Bottles
• Brief-TSF can assist patients cease alcohol consumption.

Biomarkers in Alcohol Misuse: Their Role in the Prevention and Detection of Thiamine Deficiency

In Western countries alcohol misuse is the most frequent cause of thiamine (vitamin B1) deficiency (TD) and consequent neuro-impairment.

Studies have demonstrated that between 30 and 80% of alcoholics are thiamine deficient, and this puts them at risk of developing the Wernicke–Korsakoff (WK) syndrome.

The relative roles of alcohol and TD in causing brain damage remain controversial and it is important to try to determine the role played by each factor.

Animal studies support an additive effect of alcohol exposure and TD, and indicate the potential for interaction between alcohol and TD in human alcohol-related brain damage.

Early diagnosis of alcohol-related TD is therefore an important aspect of effective intervention and treatment.

Alcohol biomarkers provide a direct and indirect way of estimating the amount of alcohol being consumed, the duration of ingestion and the harmful effects that long-term alcohol use has on body functions.

Appropriate use of these markers is very helpful when considering a diagnosis of alcohol-related TD.

Research report; Rosanna Mancinelli, and Mauro Ceccanti. Biomarkers in Alcohol Misuse: Their Role in the Prevention and Detection of Thiamine Deficiency. Alcohol and Alcoholism 2009 44(2):177-182;

See also;

• 12-Step Treatment More Effective than Alternative
• AA Offers Recovery Not Religion
• AA and Treatment Work Better Together

I’ll Quit Tomorrow: A Practical Guide to Alcoholism Treatment

The Alcohol Use Disorders Identification Test (AUDIT) as screening instrument for adolescents.

BACKGROUND: The Alcohol Use Disorders Identification Test (AUDIT) is an international screening instrument extensively employed in adult target groups. However, there is scarce information on screening with the AUDIT in adolescent populations.

The purpose of this study was to determine the cut-off point for hazardous, harmful, and dependent alcohol use through the validation of the AUDIT in a Chilean adolescent sample.

METHODS: The original English version of the AUDIT was translated into Spanish, using the procedure recommended by the World Health Organization. The text was then back-translated and sent to one of the original authors (Thomas Babor), who approved the translation. Students attending public schools in Santiago, Chile, self-administered the AUDIT, and those older than 15 years completed the

Composite International Diagnostic Interview-Substance Abuse Module (CIDI-SAM), which served as a gold standard. Between 1 and 4 weeks after the CIDI-SAM, participants answered a second AUDIT.

RESULTS:

• A total of 42 female and 53 male adolescents (mean age: 15.9 [SD=1.2]) completed the AUDIT, with a mean score of 4.3.
• Reliability according to Cronbach’s alpha was 0.83.
• Test-retest correlation was also satisfactory (intra-class correlation 0.81 [95% CI 0.73-0.87]).
• Analysis of the receiver operating characteristic (ROC) curve yielded cut-off points for hazardous, harmful, and dependent alcohol use of 3, 5, and 7 points, respectively.

CONCLUSIONS: The Chilean version of the AUDIT is a valid and reliable tool for identifying adolescents with hazardous, harmful, and dependent alcohol use. The suggested cut-off points make screening with the AUDIT more accurate for adolescent populations.

Research; Drug Alcohol Depend. 2009 Aug 1;103(3):155-8. Epub 2009 May 6. The Alcohol Use Disorders Identification Test (AUDIT) as a screening instrument for adolescents. Santis R, Garmendia ML, Acuña G, Alvarado ME, Arteaga O.

• See also;
• 12-Step Treatment More Effective than Alternative
• Brief-TSF ASSESSMENT
• Brief-TSF can assist patients cease alcohol consumption.
• Learn about the disease

Youth With Alcohol and Drug Addiction: Escape from Bondage (Helping Youth With Mental, Physical, and Social Challenges) by Kenneth McIntosh

Different Like Me: A Book for Teens Who Worry About Their Parent’s Use of Alcohol/Drugs by Evelyn Leite

Helping Helps the Helper

Aims; The helper therapy principle suggests that, within mutual-help groups, those who help others help themselves. The current study examines whether clients in treatment for alcohol and drug problems benefit from helping others, and how helping relates to 12-step involvement. Design Longitudinal treatment outcome.

Participants; An ethnically diverse community sample of 279 alcohol- and/or drug-dependent individuals (162 males, 117 females) was recruited through advertisement and treatment referral from Northern California Bay Area communities. Participants were treated at one of four day-treatment programs.

Measurements; A helping checklist measured the amount of time participants spent, during treatment, helping others by sharing experiences, explaining how to get help and giving advice on housing and employment. Measures of 12-step involvement and substance use outcomes were administered at baseline and a 6 month follow-up.

Findings; Helping and 12-step involvement emerged as important and related predictors of treatment outcomes. In the general sample, total abstinence at follow-up was strongly and positively predicted by 12-step involvement at followup, but not by helping during treatment; still, helping positively predicted subsequent 12-step involvement. Among individuals still drinking at follow-up, helping during treatment predicted a lower probability of binge drinking, whereas effects for 12-step involvement proved inconsistent.

Conclusions; Findings support the helper therapy principle and clarify the process of 12-step affiliation.

Research report; Sarah E. Zemore, Lee Ann Kaskutas & Lyndsay N. Ammon, In 12-step groups, helping helps the helper. Addiction; March 2004

Peer Support in Action: From Bystanding to Standing By

Bipolar Patients with Comorbid Substance Use Disorders; Diagnostic and Treatment Considerations:

Comorbidity of bipolar disorder (BD) and alcoholism and substance use disorders (SUDs) represents a serious public health problem and a major challenge to treatment systems.

Bipolar disorder is among the top causes of disabilities worldwide, and reportedly the fourth leading mental illness as a source of disease burden in established market economies. Large epidemiologic surveys in the United States have consistently confirmed a high association between bipolar disorder and SUDs. The Epidemiological Catchments Area Study reported bipolar I and bipolar II disorders as having the highest association with SUDs when compared with any other major psychiatric disorder.

The prevalence of lifetime alcohol abuse or dependence in persons with bipolar I disorder and bipolar II disorders were found to be 46%, and 39.2% respectively.

Similarly, the National Comorbidity Survey reported respondents with mania to be 8 to 9 times more likely to have an additional lifetime disorder of drug or alcohol dependence compared with the general population. The most recent and largest epidemiologic survey of more than 42,000 respondents in the United States, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), reported that mania and hypomania were associated with very high rates of SUDs. Those with mania were 6 times more likely to have alcohol dependence and 14 times more likely to have drug dependence over the past 12 months.

Research from; Psychiatric Annals, Volume 38 · Number 11, NOVEMBER 2008

There is a long-recognized association between alcohol consumption and aggressive behavior. But does aggression and hostility continue into sobriety?

This study was designed to examine aggression in a group of socially well-adapted recovered alcoholics.

The question addressed was whether the treatment, together with long-term abstinence from alcohol, could reduce aggression and hostility in recovered alcoholics.

Sixty four male stable alcoholics with at least 3 years sobriety were compared with 69 non-alcoholics. Neither group had any other psychological problems.

Both groups were given a questionnaire on general characteristics as well as aggressive and hostility traits.

After a 3-year abstinence, men from the recovering alcoholics group displayed greater signs of hostility and covert aggression. They were different from non-alcoholics on measures for indirect aggression, irritability, negativism, suspicion, resentment, and guilt.

Research report; Ziherl S, Cebasek Travnik Z, Kores Plesnicar B, Tomori M, Zalar B. Trait aggression and hostility in recovered alcoholics. Eur Addict Res 2007; 13(2): 89-93.

Handbook of Alcoholism

While the war on drugs continues to attract world attention, it is often overlooked that alcoholism remains a major worldwide health concern. No matter what your expertise, the Handbook of Alcoholism can help you acquire the necessary skills to treat problem drinkers and alcohol-dependent patients. In three sections;

• Patient Care,
• Research, and
• Useful Data and Definitions

this comprehensive handbook not only addresses the underlying psychological problems of alcoholism, but helps you to better diagnose and treat the non-psychiatric medical disorders caused by the disease.

See also;

• 12-Step Treatment More Effective than Alternative
• AA Offers Recovery Not Religion
• Brief-TSF is designed to as adjunctive therapy for anti-craving medication.
• Subscribe to Twelve Step Facilitation by e-Mail

Handbook of Alcoholism Treatment Approaches (3rd Edition) by Reid K. Hester, William R. Miller Read more about this title…

The Twelve-Step Facilitation Handbook: A Systematic Approach to Early Recovery from Alcoholism and Addiction by Joseph Nowinski, Stuart Baker Read more about this title…

Alcoholics and Loss of control of drinking

Alcoholics and addicts can attest to their countless attempts to stop or cut back on their drinking or drugging. They learn but cannot really accept that they have no power over alcohol or drugs.

The following research of the 1970’s began to explore this phenomenon and in the process confirming a basic tenet of Alcoholics Anonymous.

We alcoholics are men and women who have lost the ability to control our drinking. We know that no real alcoholic ever recovers control. All of us felt at times that we were regaining control, but such intervals – usually brief – were inevitably followed by still less control, which led in time to pitiful and incomprehensible demoralization. We are convinced to a man that alcoholics of our type are in the grip of a progressive illness. Over any considerable period we get worse, never better. Alcoholics Anonymous, pp 30.

Abstract of research report; This study evaluates the ability of alcoholics to regulate their blood alcohol levels (BAL) within a designated range by relying primarily on interoceptive (internal) cues. Forty male alcoholics and 20 control subjects were exposed to an initial training session in which they received sufficient ethanol to maintain them within a designated BAL range over a 2 1/2-hour period.

They were then exposed to two experimental sessions, one providing "overfeedback" and one "underfeedback." During each session, subjects had ten drinking decisions to make with respect to regulation of their BAL.

The results indicated that alcoholics displayed greater "loss-of-control" than control subjects.

This finding supported the hypothesis that alcoholics may possess a neurophysiologic feedback dysfunction that contributes to their relative inability to regulate ethanol intake.

A. M. Ludwig, F. Bendfeldt, A. Wikler and R. B. Cain. Loss of control in alcoholics. Archives of General Psychiatry. Vol. 35 No. 3, March 1978.

Safe Treatment of Pain in the Patient With a Substance Use Disorder

Conditions associated with severe pain can and do develop in persons who have active addiction or who are in remission from an addictive disease, and these patients may require treatment for pain relief. This presents a challenge to clinicians: How can pain be relieved in these patients without exacerbating or reactivating the addictive disorder?

There is little research data on this topic; however, experiential and anecdotal reports collected over the past 3 decades indicate that there are safe and effective approaches to pain management in these patients. In general, the pain treatment regimen for a person recovering from an addiction involves the use of long-acting opioids, such as sustained-release oxycodone, methadone, or buprenorphine, administered on a fixed dosage schedule, with another person holding the medication. Specific dosing recommendations are provided.

By: Penelope P. Ziegler, MD; Psychiatric Times (CMP Medica), 24(1), 2007.

HTML available online at: http://www.psychiatrictimes.com/showArticle.jhtml?articleID=196902132 (Free registration may be required.)

Brief-TSF professional training is complimentary to pain treatment.

Research Evidence for Twelve Step Facilitation

Tonigan, J. Scott1. (2001). Benefits of Alcoholics Anonymous attendance: Replication of findings between clinical research sites in Project MATCH. Alcoholism Treatment Quarterly. Vol 19(1), , US: Haworth Press Inc. 2001, 67-77.

Project MATCH Research Group. (1998). Matching alcoholism treatments to client heterogeneity: Project MATCH three year drinking outcomes. Alcoholism: Clinical and Experimental Research. Vol. 22. No. 6.

“At three years follow-up, . . . , a significantly higher abstinence rate was found with TSF clients. Among TSF clients 36% were abstinent, compared with 27% of Motivational Enhancement Therapy and 24% of Cognitive Behavioural Therapy clients (p< 0.007).”

Patient-Treatment Matching, National Institute on Alcohol Abuse and Alcoholism, Alcohol Alert No. 36, April 1997

“. . . in the outpatient group, 10 percent more patients who received TSF achieved continuous abstinence compared with those who received the other two treatments (24 percent for TSF as opposed to 15 percent for CBT and 14 percent for MET).”

Tonigan, J. Scott: Miller, William R: Connors, Gerard J. (2000), Project MATCH client impressions about Alcoholics Anonymous: Measurement issues and relationship to treatment outcome. Alcoholism Treatment Quarterly. Vol 18(1), 2000, 25-41.

Saunders, John B. The efficacy of treatment for drinking problems. International Review of Psychiatry. Vol 1(1-2), Mar 1989, 121-137.

National Drug and Alcohol Research Centre (NDARC) Commonwealth Department of Health and Ageing. Guidelines for the Treatment of Alcohol Problems. June 2003.

Blondell RD.Looney SW. Northington AP. Lasch ME. Rhodes SB. McDaniels RL. Using recovering alcoholics to help hospitalized patients with alcohol problems. Journal of Family Practice, 50(5):E1, 2001 May.

CONCLUSIONS: Among trauma victims with injuries severe enough to require hospital admission, brief advice from a physician followed by a visit with a recovering alcoholic appears to be an effective intervention. Although further study is needed to confirm these findings, in the meantime physicians can request that members of Alcoholics Anonymous (AA) visit their hospitalized patients who have alcohol use disorders. Interventions by recovering alcoholics are part of their twelfth-step work (an essential part of the AA program) and are simple, practical, involve no costs, and pose little patient risk. They can be arranged from the patient’s bedside telephone. Some patients will show a dramatic response to these peer visits.

Riordan, Richard J.; Walsh, Lani. Guidelines for professional referral to alcoholics anonymous and other twelve step groups. Journal of Counseling & Development, Mar/Apr94, Vol. 72 Issue 4, p351.

Sisson Rw & Mullams JH. (1981) The use of systematic encouragement and community access procedures to increase attendance at AA and Alanon meetings. American J of Drug & Alcohol Abuse. V8(3), 371-6.

Participation in Alcoholics Anonymous: Intended and Unintended Change Mechanisms. (Proceedings of Symposium at the 2001 RSA Meeting) Alcoholism: Clinical & Experimental Research, Volume 27(3)., March 2003, pp 524-532. 2003Research Society on Alcoholism.

Summary:

• AA cannot be ignored in understanding treatment outcomes.
• It is possible to facilitate AA attendance.
• Treatment is the time to do it.
• Attendance is not involvement.
• AA participation predicts better outcomes.
• Continuous abstinence is the outcome most likely to be affected by AA.
• The abstinence message of AA does not seem to be deleterious.

Humphreys, Keith. Professional interventions that facilitate 12-step self-help group involvement. Alcohol Research & Health. Vol 23(2), 1999, 93-98.

It is concluded that health care professionals can influence participation in TSF groups.

Caldwell PE. (1999) Fostering client connections with Alcoholics Anonymous; A framework for Social Workers in various practice settings. Social Work in Health Care, V28(4), 45-61.

Parker J & Guest DL, (1999) The clinicians guide to 12-step programs; How, when and why to refer a client. Auburn House; Westport.

TSF shows good effect on behaviors that are generally accepted outcomes.

Robert F. Forman, PhD, Charles Dackis, MD, Rick Rawson, PhD. (2004). Substance abuse: 12 principles to more effective outpatient treatment.

Patients who participate in 12-step programs and treatments have better outcomes than those who do not.

Sheeren. Journal of Studies on Alcohol, 49:104, 1988.

• AA Should be considered essential in treatment of addictive disorders and
• AA reduces relapse

Humphreys, Keith; Moos, Rudolf. Volume 25(5) May 2001 pp 711-716. Can Encouraging Substance Abuse Patients to Participate in Self-Help Groups Reduce Demand for Health Care?

Conclusion; “Professional treatment programs that emphasize self-help approaches increase their patients’ reliance on cost-free self-help groups and thereby lower subsequent health care costs. Such programs therefore represent a cost-effective approach to promoting recovery from substance abuse.”

Riordan, Richard J.; Walsh, Lani. Guidelines for professional referral to alcoholics anonymous and other twelve step groups. Journal of Counseling & Development, Mar/Apr94, Vol. 72 Issue 4, p351.

“ . . . support groups such as AA can serve several adjunctive goals in a counselor’s treatment plan. In the early phases, clients may be very needy as they work through the denial, guilt, and shame, as well as the craving. They may need almost constant support. The counselor cannot realistically be available on a 7-days-a-week basis; AA, however, is. Likewise, in a long-term counseling relationship, AA can be an ally to the counselor, providing extra foundation and support as the client works through more deeply seated issues.”

Smart, Reginald G; Mann, Robert E. Recent liver cirrhosis declines: Estimates of the impact of alcohol abuse treatment and Alcoholics Anonymous. Addiction. Vol 88(2), Feb 1993, 193-198.

• AA has been found to be a significant contributor to reductions in cirrhosis mortality & morbidity.
• An increase of 1.0% in AA membership reduces cirrhosis mortality by 0.06%.

Kaner EF, Wutzke S, Saunders JB, Powell A, Morawski J, Bouix JC; WHO Brief Intervention Study Group. Impact of alcohol education and training on general practitioners’ diagnostic and management skills: findings from a World Health Organization collaborative study. J Stud Alcohol. 2001 Sep;62(5):621-7

CONCLUSIONS: Greater exposure to alcohol-related Continuing Medical Education (CME) appears to result in better diagnosis and more appropriate management of alcohol-related problems by GPs.

Longabaugh R, Wirtz PW, Zweben A, Stout RL. Network support for drinking, Alcoholics Anonymous and long-term matching effects. Addiction. 1998 Sep;93(9):1313-33.

“CONCLUSIONS:

• In the long-term TSF may be the treatment of choice for alcohol-dependent clients with networks supportive of drinking;
• Involvement in AA should be given special consideration for clients with networks supportive of drinking, irrespective of the therapy they will receive.”

There is a need for best practice education in alcoholism intervention

Walsh, R A; Sanson-Fisher, R W; Low, A; Roche, A M. Teaching medical students alcohol intervention skills: results of a controlled trial. Volume 33(8) August 1999 pp 559-565

“Conclusions: Training can improve medical student performance in alcohol intervention”

Peter Anderson, Eileen Kaner, Sonia Wutzke, Michel Wensing, Richard Grol1, Nick Heather and John Saunders. ATTITUDES AND MANAGEMENT OF ALCOHOL PROBLEMS IN GENERAL PRACTICE: Alcohol & Alcoholism Vol. 38, No. 6, pp. 597-601, 2003

Conclusion: Both education and support in the working environment need to be provided to enhance the involvement of GPs in the management of alcohol problems.

Mark A. Perini, MD, Alcoholics Anonymous and Drug Therapy in the Treatment of Alcohol Abuse and Dependence. Wake Forest University Baptist Medical Center, Internal Medicine Residency Program, September 26, 2000.

In summary,

• There is evidence supporting a recommendation to attend Alcoholics Anonymous in the literature. One can feel comfortable in stating the following learning points:
• Alcoholics Anonymous (AA) is a safe, low cost, widely available tool of behavioral change that strives to capitalize on the patient’s inner motivation and spirituality.
• AA should be part of any attempt at treatment of alcohol abuse or dependence.
• Success with AA can be enhanced by a twelve-step facilitation treatment implemented concomitantly with AA attendance.
• Referring patients to AA groups composed of individuals of similar age, cultural, and occupational status may improve attendance and outcomes as well.

A World Health Organization Working Group has listed the competencies needed by primary health care doctors and teams for the successful management of potential or established alcohol-related problems:

• a knowledge of the prevalence of hazardous and harmful alcohol consumption and related physical, psychological and social problems;
• a knowledge and appreciation of the effects of patients’ alcohol problems on their partners and families;
• an awareness of the patients’ personal attitudes to alcohol;
• the ability to identify the various physical, psychological and social indications of a drinking problem;
• the ability to communicate accurate information on alcohol and alcohol-related problems, in an appropriate context, to patients and their relatives;
• the ability to distinguish between low-risk, harmful and dependent levels of alcohol consumption;
• the ability to manage the physical consequences and complications of acute intoxication;
• the ability to take an accurate drinking history;
• the ability to recognise signs of alcohol-related disease;
• the ability to interpret laboratory tests accurately;
• the ability to choose an appropriate management plan (brief intervention or referral to appropriate colleagues or clinics);
• and the ability to direct and manage the detoxification of patients at home.

TSF and Alcoholics Anonymous are well accepted by providers and clients.

Twelve-Step Orientated Residential Treatment Programs: A Review. (March 2000) Richard Csiernik, Ph.D. School of Social Work, King’s College, University of Western Ontario, London, Ontario

The treatment modality with the longest successful history of rehabilitating alcoholics is a mutual aid/self-help program, Alcoholics Anonymous(A.A.). From A.A. has germinated a network of similar twelve-step approaches that are the most readily accessible means for maintaining abstinence. Individuals with an addiction problem may join a twelve step group on their own or may be introduced to the idea and the process through participation in a formal treatment program.

Vaillant, G. E. (1983). The natural history of alcoholism. Cambridge, MA: Harvard University Press.

Conclusion: that there are many alcohol-dependent individuals regardless of social or psychological make-up who find help for alcoholism through AA. It seems prudent to consider a referral to AA for all alcoholic clients except for those with significant pathology.

Friedmann PD, McCullough D, Chin MH, Saitz R Screening and intervention for alcohol problems a national survey of primary care physicians and psychiatrists. Journal of General Internal Medicine 2000, 15.~4-91, 2000.

The majority of physicians said that they usually or always recommended 12 Step groups to problem drinking patients

Chang, Grace; Astrachan, Boris M; Bryant, Kendall J. Emergency physicians’ ratings of alcoholism treaters. Journal of Substance Abuse Treatment. Vol 11(2), Mar-Apr 1994, 131-135.

Physician agreement on the efficacy of alcoholism treaters was greatest for AA (87%), moderate for mental health professionals (including psychiatrists and psychologists, 55%) and least for physicians and surgeons (excluding psychiatrists, 23%).

Roche AM, Parle MD, Stubbs JM, Hall W, Saunders JB. Management and treatment efficacy of drug and alcohol problems: What do doctors believe. Addiction. 1995;90:1357-66.

A majority of post graduate doctors believed Alcoholics Anonymous to be the referral of choice for alcoholism.

Norman Swan. Naltrexone and Alcohol Dependence. The Health Report, ABC Radio National. Broadcast Monday 1 July 2002

Professor John Saunders: “Some of the alcohol-dependent patients that I have seen over the years have achieved the most stable and rewarding recovery through regular attendance at Alcoholics Anonymous. For example, of the 300,000 to 400,000 alcohol-dependent people in Australia, only 20,000 are regular attenders of AA. I wish more people did attend regularly because I do think it provides very considerable benefit.”

• The Alcoholics Anonymous 2001 Membership Survey reveals a wide cross section of demographics. Age of members ranging from teenagers to over 70 years, of both genders, varied ethnic groups and from all occupations. Only a third of members self-referred to AA with the majority being referred by professionals (38%), family or friends. Sixty one percent attended some form of treatment before attending AA and 64% received some form of treatment after joining.
• Current global membership of AA is estimated to be 2 million people with some 30,000 in Australia.
• The participation rate in AA in the USA and most westernized countries is approximately 5 per 1000 of the adult population (age 15 yrs plus). The Australian AA participation rate is approximately 2 per 1000 adult population. There is room for growth.
• By comparison the participation rate in formal treatment services for alcohol in Australia is approximately 1.9 per 1000 population.

AIHW: Alcohol and other drug treatment services in Australia: Findings from the National Minimum Data Set 2000-01. AIHW Cat. No. AUS 30. Canberra: AIHW.

TSF is based on a clear and well-articulated theory.

Joseph Nowinski, Twelve-Step Facilitation, Approaches to Drug Abuse Counseling. U.S. Department of Health and Human Services, National Institutes of Health. Dual Diagnosis Recovery Network.

Wallace J. (1996) Chapter 1; Theory of 12-step oriented treatment. IN, Roger F, Keller DS & Morgenstern J. Treating substance abuse; theory and technique. The Guilford Press, New York.

Miller WR & Kurtz E. (1994) Models of alcoholism used in treatment; contrasting AA and other perspectives with which it is often confused. J of Studies on Alcohol. V55, 159-66.

Khantzian EJ, Mack JE. (1994) How AA works and why it’s important for clinicians to understand. J of Substance Abuse Treatment. V11(2), 77-92.

Chappel JN. (1997) Spirituality and addiction psychiatry. IN – Miller NS The principles and practices of addictions in psychiatry. WB Saunders; Philadelphia.

Burkhardt MA & Nagai-Jacobson MG. (1997) Spirituality and Healing. IN, Dossey BM (Ed) Core Curriculum for Holistic Nursing. Aspen Publishers, American Holistic Nurses Association, Maryland.

Steffen V. (1997) Life stories and shared experience. Soc Sci Med. V45(1), 99-111.

Bradley, A. M. (1988). Keep coming back: The case for a valuation of Alcoholics Anonymous. Alcohol Health and Research World,12, 192-199.

Tonigan, J.S., Connors, G.J. & Miller, W.R. (1996) The Alcoholics Anonymous Involvement (AAI) Scale: Reliability and norms. Psychology of Addictive Behaviors, 10(2), 75-80.

Alcoholics Anonymous shows good retention rates for clients.

William W (1994) The society of AA; 1949. (Classic reprint) Am J Psychiatry. V151(6), 259-62.

Humphreys K; Huebsch PD; Finney JW; Moos RH. A comparative evaluation of substance abuse treatment: V. Substance abuse treatment can enhance the effectiveness of self-help groups. Alcoholism: Clinical and Experimental Research 23(3): 558-563, 1999.

“Affiliation with Alcoholics Anonymous (AA) and other 12-Step self-help groups is becoming more common at the same time as professional substance abuse treatment services are becoming less available and of shorter duration. As a result of these two trends, patients’ outcomes may be increasingly influenced by the degree to which professional treatment programs help patients take maximum advantage of self-help groups.”

Moos RH; Finney JW; Ouimette PC; Suchinsky RT. A comparative evaluation of substance abuse treatment: I. Treatment orientation, amount of care, and 1-year outcomes. Alcoholism: Clinical and Experimental Research 23(3): 529-536, 1999.

“The study was conducted among 3018 patients from 15 Veterans Affairs programs that emphasized 12-Step, cognitive-behavioral (CB), or eclectic treatment. Casemix-adjusted 1-year outcomes showed that patients in 12-Step programs were the most likely to be abstinent, free of substance abuse problems, and employed at the 1-year follow- up. These findings support the effectiveness of 12-Step treatment and show that patients with substance use disorders who become more involved in outpatient care and self-help groups tend to experience better short-term substance use outcomes”

TSF addresses cultural diversity and different populations.

Gabriele Bardazzi, Andrea Quartini, Grazia Filippini, Maria Luisi Marcias, Alberto Centurioni, Ginetta Fusi, Allaman Allamani (1999) Cost-effectiveness in the treatment of alcohol abuse: a treatment program experience. Journal For Drug Addiction And Alcoholism. 22nd year: 1999 no 4.

Tonigan JS. Miller WR. Schermer C. Atheists, agnostics and Alcoholics Anonymous. Journal of Studies on Alcohol. 63(5):534-41, 2002 Sep.

Timko, Christine; Moos, Rudolf H.; Finney, John W.; Connell, Ellen G. Gender differences in help-utilization and the 8-year course of alcohol abuse. Addiction, Volume 97(7) July 2002 p 877-889.

“Conclusions: The results suggest that although alcoholism interventions were designed primarily for men, they are currently delivered in ways that are also useful to women. Problem-drinking women appear to benefit from sustained participation in AA, which emphasizes bonding with supportive peers to maintain abstinence.”

Gabhainn, S.N. Assessing sobriety and successful membership of Alcoholics Anonymous. Journal of Substance Use, 8(1):55-61, 2003. (168538)

“There were few differences across sociodemographic groups in perceived successful membership.”

Humphreys K. (196) Worldview change in adult children of Alcoholics/ Alanon self-help groups; reconstructing the alcoholic family. Int J of Group Psychotherapy. V46(2), 255-63.

Kramer TH & Hoisington D. (1992) Use of AA & NA in the treatment of chemical dependencies of traumatic brain injury survivors. Brain Injury. V6(1), 81-8.

Kus RJ (1988) “Working the Program”; The Alcoholics Anonymous experience and gay American men. Holistic Nursing Practice. August, pp 62-74.

Obuchwsky M & Zweben JE. (1987) Bridging the gap; The methadone client in 12-step programs. J of Psychoactive Drugs. V19(3), 301-2.

McGonagle D. (1994) Methadone Anonymous; A 12-STEP PROGRAM. Reducing the stigma of methadone use. J Psychosoc Nurs Ment Health V32(10), 5-12.

Cermak TL. Al-Anon and recovery. Recent Dev Alcohol 1989;7:91-104

Humphreys K; Ribisl KM. The case for a partnership with self-help groups. (editorial). Public Health Reports. V114(4): 322-329, 1999.

“This essay discusses the origins and nature of self-help groups. The authors note three ways they can be effective in addressing public health issues: (1) By offering accessible and effective interventions for specific problems; (2) By enhancing profesionally run health promotion and health care programs; and (3) By enriching community life and building a base for public health advocacy. An organization the American Self-Help Clearinghouse is noted.”

Vaughn C; Long W. Surrender to win: How adolescent drug and alcohol users change their lives. Adolescence, 34(133): 9-24, 1999.

This paper offers a phenomenological analysis of seven young adults who managed to surrender their addictions and, for anywhere from five to fifteen years, construct sober identities. The participants came from highly dysfunctional homes, began substance use as children, and were polydrug users. A series of catastrophic life events led them to Alcoholics Anonymous, where they were exposed to self-reflective prayer, a cadre of recovering adolescents and, in particular, adults who offered detached nurturing. This provided the support they needed to confront their addictions through the Twelve Steps of Alcoholics Anonymous.

TSF can be used by staff with a wide diversity of backgrounds and training.

Riessman F. (1965) The ‘Helper’ therapy principle. Social Work. April.

Borkman T (1976) Experiential knowledge; a new concept for the analysis of self-help groups. Social Service Review. (Sep), 445-56.

Davis DR & Jansen GG. (1998) Making meaning of Alcoholics Anonymous for social workers; Myths, metaphors and realities. Social Work. V43(2), 169-82.

Nowinski J, Baker S, Carroll KM. Twelve-Step facilitation therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. NIAAA Project MATCH Monograph Series, vol. 1. DHHS Pub. No. (ADM)92-1893. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, 1992.

Nowinski J. (1996) Chapter 2; Facilitating 12-step recovery from substance abuse and addiction. IN, Roger F, Keller DS & Morgenstern J. Treating Substance Abuse; Theory and Technique.

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Wheeler, Sue; Turner, Linda. Counselling problem drinkers: The realm of specialists, Alcoholics Anonymous or generic counsellors. British Journal of Guidance & Counselling, Aug97, Vol. 25 Issue 3, p313.

Counsellors usually had some knowledge of AA but had little understanding of the 12-step programme that forms the basis of recovery for alcoholics as described by AA. They were, however, in favour of clients attending AA as an adjunct to individual counselling.

Tobie L Sacks and Nicholas A Keks. (No date) Medical Journal of Australia, Practice Essentials, Mental Health #14, Alcohol and drug dependence: diagnosis and management