Robert F. Forman, PhD

Attending the wrong 12-step meeting can turn off some patients, despite the substance abuse treatment support offered by Alcoholics Anonymous (AA) and similar programs. Because of the stigma associated with alcohol or drug addiction, most patients are ambivalent at best about attending their first 12-step meetings. Feeling “out of place”—the most common turn-off—can transform this ambivalence into adamant resistance.

Simply advising an addicted patient to “call AA” is tantamount to giving a depressed patient a copy of the Physicians’ Desk Reference and telling him or her to pick an antidepressant. Not all 12-step meetings are alike; 50,000 AA meetings are held every week in the United States (Box 1).^1-7 Recognizing the differences between the groups in your area will help you guide your patients to the best match.

In prescribing a 12-step program, consider these six patient factors: socioeconomic status, gender, age, attitude towards spirituality, smoking status, and drug of choice.

Box 1

Socioeconomic status

Matching patients with meetings according to socioeconomic status is not elitist—it’s pragmatic. Patients generally feel most comfortable and relate most readily at meetings where they feel they have something in common with the other members. For example, when a newly recovering middle-class alcoholic visits an AA group that is frequented by homeless and unemployed alcoholics, chances are that he will become more ambivalent about attending meetings. After all, he was never “that bad.”

A good practice is to give your patients an up-to-date 12-step meeting directory (Box 2). Suggest that they identify the meetings where they think they will feel most comfortable, based on the neighborhoods in which they are held.

Patients in early recovery often are terrified of encountering someone they know at a 12-step meeting. One strategy for patients concerned about protecting their anonymity—as many are—is to attend meetings outside their own neighborhoods but still in areas that match their socioeconomic status. Similarly, referring patients to meetings that are “closed to members only” might reduce their concerns about exposure.

Once a patient has connected with a 12-step program, matching by socioeconomic status becomes less important. Many begin to see similarities between themselves and other addicted individuals from all walks of life. In the beginning, however, similarities attract.

Your patient’s gender

Though women were once a small minority in AA and Narcotics Anonymous (NA), today they make up about one-third of AA’s membership and more than 40% of NA.⁸ One factor that may have boosted the number of women attending 12-step programs is the increased availability of women-only meetings.

Most cities have women-only meetings, and they generally will be a good place for your female patients to begin. Evidence indicates that gender-specific treatment enhances treatment outcomes.^9,10 Women-only meetings tend to be smaller than mixed groups, and the senior members are often particularly willing to welcome newcomers.

Although it is severely frowned upon, the phenomenon of AA or NA members attempting to become romantically or sexually involved with a newcomer is common enough that 12-step members have coined a term for it: “13-stepping.” Newly recovering patients are often emotionally vulnerable and at risk of becoming enmeshed in a potentially destructive relationship. Beginning recovery in gender-specific meetings helps to reduce this risk.

Your patient’s age

A 12-step meeting dominated by people with gray, blue, or no hair can quickly put off teens and young adults in early recovery. Though these meetings with older members are likely to include persons who have achieved long-term and healthy recovery (making such meetings ideal territory for finding a sponsor), finding peers of a similar age is also important.

Meetings intended for young people are identified in 12-step meeting directories, but many of these “young peoples’ ” meetings have a preponderance of members older than 30—quite ancient by a 16-year-old’s standards. Conversely, some generic 12-step meetings might have a cadre of teenagers that attend regularly—at least for a while.

In AA and NA, teens and young adults tend to travel in nomadic packs, linger for a few months, then move on. For this reason, having contacts familiar with the characteristics of local meetings can be invaluable as you try to match a younger patient with a 12-step meeting.

Attitude toward spirituality

One of patients’ most common complaints about 12-step meetings is their surprise at how “religious” the programs are. Insiders are quick to point out that 12-step programs are “spiritual” and not “religious,” but the distinction is moot to patients who are uneasy with this aspect of meetings. The talk about “God as I understand Him,” the opening and closing of meetings with prayers, and the generous adoption of Judeo-Christian practices can rub agnostic, atheistic, and otherwise spiritually indifferent patients the wrong way.

To protect your patients from being blind-sided, review with them some of the spiritual practices employed in 12-step programs before they attend their first meeting:

• Meetings begin with reading the Twelve Steps (Box 3) and other 12-step literature; all readings are peppered with spiritually-loaded words such as “God,” “Higher Power,” “prayer,” and “meditation.”
• Meetings end with a prayer in which the group stands and holds hands (in AA) or links their arms in a huddle (NA). [I advise patients who might find this activity intolerable to duck out to the rest room 5 minutes before the meeting ends.]
• Group leaders typically collect donations by passing the basket.

Certain meetings have a particularly heavy spiritual focus and might be appropriately prescribed for patients hungering for spiritual growth. But for patients who have had toxic encounters with religion or otherwise are ill-at-ease with spirituality or religious matters, starting out at one of the more spiritually hardcore 12-step meetings could be overwhelming. While your 12-step contact person is your best guide in these matters, the following points also apply:

• Meetings listed as “11th Step” or “God as I understand Him” meetings will have a strong spiritual focus.
• Meetings held on Sunday mornings often have the express purpose of focusing on spirituality.
• “Step” meetings generally have a more spiritual focus, as 11 of the 12 steps are aimed at eliciting a “spiritual awakening.”
• “Speaker” or “topic discussion” meetings tend to have a less spiritual focus, though this will vary with the meeting chairperson’s preferences.
• “Beginners” meetings, when available, are intended for new members and devote more time to helping the newcomer understand the 12-step approach to spirituality.

Box 2

Box 3

AA’s main text, the so-called “Big Book” (its real title is: Alcoholics Anonymous⁷) has a chapter titled, “We Agnostics.” AA has many long-time members who have found support in the fellowship but never “found God” or a belief in a higher power other than the fellowship itself. These secular 12-step members demonstrate one of the many ironies of AA and NA—that spiritual fellowships can work even for individuals who reject spirituality.

Patients who resist spirituality are advised to “take what you can use” from the fellowship and “leave the rest.” While 12-step members will propose that the newcomer keep an open mind about spirituality, patients should also be assured that a seat is always waiting for them, regardless.

Whether your patient smokes

Most 12-step meetings today are smoke-free, not because of enlightenment within the fellowships but because meetings are usually held in churches, synagogues, and health care facilities where smoking is banned. The perception that attending 12-step meetings can be harmful to your health is out-of-date. Nonetheless, because most meetings have banned smoking, the few in which smoking is allowed are thick with smoke.

In general, 12-step clubhouses are among the holdouts where smoking is allowed during and after meetings. A clubhouse is typically a storefront rented or acquired by AA/NA members where meetings are held around the clock. Given the evidence that quitting smoking may improve overall health,^10,11 patients should be encouraged to begin their involvement in smoke-free fellowships, which are identified in 12-step directories.

Your patient’s drug of choice

As its name implies, AA is intended for persons who desire to stop drinking. In practice, however, much of AA’s membership is addicted to more than one substance, and—in some cases—the drug of choice might not be alcohol.

Narcotics Anonymous—contrary to what its name implies—is for individuals addicted to any drug, not just narcotics. Patients generally should be advised to join the fellowship (AA or NA) that best matches their substance use history. There is, however, at least one exception that might best be illustrated with an example:

After I recommended NA meetings to a middle-class nurse addicted to analgesics, she returned for her next appointment quite angry. She attended three different NA meetings, and “all of the members were either heroin or crack cocaine addicts.” It seemed to her that all of them were on probation or parole. She was very uncomfortable throughout the meetings and upset with my recommendation.

In matching patients with meetings, socioeconomic and cultural factors take precedence over biochemistry. At the neuronal level, a nurse addicted to analgesics has a lot in common with a heroin addict, but her ability to relate to another recovering person—particularly in early recovery—may be limited. Arguing with my patient or countering that other nurses were probably at the meetings she attended would not have eased her reluctance to return to NA or helped our therapeutic alliance.

NA meetings are generally attended by individuals addicted to illicit drugs: amphetamines, crack cocaine, cannabis, and heroin. In larger cities, other 12-step fellowships may focus on specific drugs, such as cocaine, but these are rare. Just as individuals addicted to prescription narcotics are a minority in the treatment population, they are also a minority in NA.

For this reason, our prior recommendation—to match patients to meetings based on socioeconomic status—applies. It’s good policy to recommend that patients addicted to prescription medications try both AA and NA meetings and decide where they feel most comfortable.

The third tradition of AA states, “the only requirement for AA membership is a desire to stop drinking.” Though a purist might suggest that our analgesics-dependent nurse should join NA, her need to connect culturally with similar persons in recovery argues strongly for her to blend in at open AA meetings. A social drinker who never fulfilled the diagnostic criteria for alcohol dependence, she will have a better chance of abstaining from analgesics if she abstains from alcohol as well. For this reason, she should qualify for AA membership because she does, in fact, have “a desire to stop drinking.”

Some professionals addicted to prescription drugs will feel at home in NA meetings, whereas others will react as my patient did. Having access to a 12-step contact person who knows about the demographics of local NA meetings can help you make the best patient/meeting match.

Related resources

• Alcoholics Anonymous. www.alcoholics-anonymous.org
• Narcotics Anonymous. www.na.org
• Alanon-Alateen. www.al-anon.org

Attending the wrong 12-step meeting can turn off some patients, despite the substance abuse treatment support offered by Alcoholics Anonymous (AA) and similar programs. Because of the stigma associated with alcohol or drug addiction, most patients are ambivalent at best about attending their first 12-step meetings. Feeling “out of place”—the most common turn-off—can transform this ambivalence into adamant resistance.

Simply advising an addicted patient to “call AA” is tantamount to giving a depressed patient a copy of the Physicians’ Desk Reference and telling him or her to pick an antidepressant. Not all 12-step meetings are alike; 50,000 AA meetings are held every week in the United States (Box 1).^1-7 Recognizing the differences between the groups in your area will help you guide your patients to the best match.

In prescribing a 12-step program, consider these six patient factors: socioeconomic status, gender, age, attitude towards spirituality, smoking status, and drug of choice.

Box 1

Socioeconomic status

Matching patients with meetings according to socioeconomic status is not elitist—it’s pragmatic. Patients generally feel most comfortable and relate most readily at meetings where they feel they have something in common with the other members. For example, when a newly recovering middle-class alcoholic visits an AA group that is frequented by homeless and unemployed alcoholics, chances are that he will become more ambivalent about attending meetings. After all, he was never “that bad.”

A good practice is to give your patients an up-to-date 12-step meeting directory (Box 2). Suggest that they identify the meetings where they think they will feel most comfortable, based on the neighborhoods in which they are held.

Patients in early recovery often are terrified of encountering someone they know at a 12-step meeting. One strategy for patients concerned about protecting their anonymity—as many are—is to attend meetings outside their own neighborhoods but still in areas that match their socioeconomic status. Similarly, referring patients to meetings that are “closed to members only” might reduce their concerns about exposure.

Once a patient has connected with a 12-step program, matching by socioeconomic status becomes less important. Many begin to see similarities between themselves and other addicted individuals from all walks of life. In the beginning, however, similarities attract.

Your patient’s gender

Though women were once a small minority in AA and Narcotics Anonymous (NA), today they make up about one-third of AA’s membership and more than 40% of NA.⁸ One factor that may have boosted the number of women attending 12-step programs is the increased availability of women-only meetings.

Most cities have women-only meetings, and they generally will be a good place for your female patients to begin. Evidence indicates that gender-specific treatment enhances treatment outcomes.^9,10 Women-only meetings tend to be smaller than mixed groups, and the senior members are often particularly willing to welcome newcomers.

Although it is severely frowned upon, the phenomenon of AA or NA members attempting to become romantically or sexually involved with a newcomer is common enough that 12-step members have coined a term for it: “13-stepping.” Newly recovering patients are often emotionally vulnerable and at risk of becoming enmeshed in a potentially destructive relationship. Beginning recovery in gender-specific meetings helps to reduce this risk.

Your patient’s age

A 12-step meeting dominated by people with gray, blue, or no hair can quickly put off teens and young adults in early recovery. Though these meetings with older members are likely to include persons who have achieved long-term and healthy recovery (making such meetings ideal territory for finding a sponsor), finding peers of a similar age is also important.

Meetings intended for young people are identified in 12-step meeting directories, but many of these “young peoples’ ” meetings have a preponderance of members older than 30—quite ancient by a 16-year-old’s standards. Conversely, some generic 12-step meetings might have a cadre of teenagers that attend regularly—at least for a while.

In AA and NA, teens and young adults tend to travel in nomadic packs, linger for a few months, then move on. For this reason, having contacts familiar with the characteristics of local meetings can be invaluable as you try to match a younger patient with a 12-step meeting.

Attitude toward spirituality

One of patients’ most common complaints about 12-step meetings is their surprise at how “religious” the programs are. Insiders are quick to point out that 12-step programs are “spiritual” and not “religious,” but the distinction is moot to patients who are uneasy with this aspect of meetings. The talk about “God as I understand Him,” the opening and closing of meetings with prayers, and the generous adoption of Judeo-Christian practices can rub agnostic, atheistic, and otherwise spiritually indifferent patients the wrong way.

To protect your patients from being blind-sided, review with them some of the spiritual practices employed in 12-step programs before they attend their first meeting:

• Meetings begin with reading the Twelve Steps (Box 3) and other 12-step literature; all readings are peppered with spiritually-loaded words such as “God,” “Higher Power,” “prayer,” and “meditation.”
• Meetings end with a prayer in which the group stands and holds hands (in AA) or links their arms in a huddle (NA). [I advise patients who might find this activity intolerable to duck out to the rest room 5 minutes before the meeting ends.]
• Group leaders typically collect donations by passing the basket.

Certain meetings have a particularly heavy spiritual focus and might be appropriately prescribed for patients hungering for spiritual growth. But for patients who have had toxic encounters with religion or otherwise are ill-at-ease with spirituality or religious matters, starting out at one of the more spiritually hardcore 12-step meetings could be overwhelming. While your 12-step contact person is your best guide in these matters, the following points also apply:

• Meetings listed as “11th Step” or “God as I understand Him” meetings will have a strong spiritual focus.
• Meetings held on Sunday mornings often have the express purpose of focusing on spirituality.
• “Step” meetings generally have a more spiritual focus, as 11 of the 12 steps are aimed at eliciting a “spiritual awakening.”
• “Speaker” or “topic discussion” meetings tend to have a less spiritual focus, though this will vary with the meeting chairperson’s preferences.
• “Beginners” meetings, when available, are intended for new members and devote more time to helping the newcomer understand the 12-step approach to spirituality.

Box 2

Box 3

AA’s main text, the so-called “Big Book” (its real title is: Alcoholics Anonymous⁷) has a chapter titled, “We Agnostics.” AA has many long-time members who have found support in the fellowship but never “found God” or a belief in a higher power other than the fellowship itself. These secular 12-step members demonstrate one of the many ironies of AA and NA—that spiritual fellowships can work even for individuals who reject spirituality.

Patients who resist spirituality are advised to “take what you can use” from the fellowship and “leave the rest.” While 12-step members will propose that the newcomer keep an open mind about spirituality, patients should also be assured that a seat is always waiting for them, regardless.

Whether your patient smokes

Most 12-step meetings today are smoke-free, not because of enlightenment within the fellowships but because meetings are usually held in churches, synagogues, and health care facilities where smoking is banned. The perception that attending 12-step meetings can be harmful to your health is out-of-date. Nonetheless, because most meetings have banned smoking, the few in which smoking is allowed are thick with smoke.

In general, 12-step clubhouses are among the holdouts where smoking is allowed during and after meetings. A clubhouse is typically a storefront rented or acquired by AA/NA members where meetings are held around the clock. Given the evidence that quitting smoking may improve overall health,^10,11 patients should be encouraged to begin their involvement in smoke-free fellowships, which are identified in 12-step directories.

Your patient’s drug of choice

As its name implies, AA is intended for persons who desire to stop drinking. In practice, however, much of AA’s membership is addicted to more than one substance, and—in some cases—the drug of choice might not be alcohol.

Narcotics Anonymous—contrary to what its name implies—is for individuals addicted to any drug, not just narcotics. Patients generally should be advised to join the fellowship (AA or NA) that best matches their substance use history. There is, however, at least one exception that might best be illustrated with an example:

After I recommended NA meetings to a middle-class nurse addicted to analgesics, she returned for her next appointment quite angry. She attended three different NA meetings, and “all of the members were either heroin or crack cocaine addicts.” It seemed to her that all of them were on probation or parole. She was very uncomfortable throughout the meetings and upset with my recommendation.

In matching patients with meetings, socioeconomic and cultural factors take precedence over biochemistry. At the neuronal level, a nurse addicted to analgesics has a lot in common with a heroin addict, but her ability to relate to another recovering person—particularly in early recovery—may be limited. Arguing with my patient or countering that other nurses were probably at the meetings she attended would not have eased her reluctance to return to NA or helped our therapeutic alliance.

NA meetings are generally attended by individuals addicted to illicit drugs: amphetamines, crack cocaine, cannabis, and heroin. In larger cities, other 12-step fellowships may focus on specific drugs, such as cocaine, but these are rare. Just as individuals addicted to prescription narcotics are a minority in the treatment population, they are also a minority in NA.

For this reason, our prior recommendation—to match patients to meetings based on socioeconomic status—applies. It’s good policy to recommend that patients addicted to prescription medications try both AA and NA meetings and decide where they feel most comfortable.

The third tradition of AA states, “the only requirement for AA membership is a desire to stop drinking.” Though a purist might suggest that our analgesics-dependent nurse should join NA, her need to connect culturally with similar persons in recovery argues strongly for her to blend in at open AA meetings. A social drinker who never fulfilled the diagnostic criteria for alcohol dependence, she will have a better chance of abstaining from analgesics if she abstains from alcohol as well. For this reason, she should qualify for AA membership because she does, in fact, have “a desire to stop drinking.”

Some professionals addicted to prescription drugs will feel at home in NA meetings, whereas others will react as my patient did. Having access to a 12-step contact person who knows about the demographics of local NA meetings can help you make the best patient/meeting match.

Related resources

• Alcoholics Anonymous. www.alcoholics-anonymous.org
• Narcotics Anonymous. www.na.org
• Alanon-Alateen. www.al-anon.org

Attending the wrong 12-step meeting can turn off some patients, despite the substance abuse treatment support offered by Alcoholics Anonymous (AA) and similar programs. Because of the stigma associated with alcohol or drug addiction, most patients are ambivalent at best about attending their first 12-step meetings. Feeling “out of place”—the most common turn-off—can transform this ambivalence into adamant resistance.

Simply advising an addicted patient to “call AA” is tantamount to giving a depressed patient a copy of the Physicians’ Desk Reference and telling him or her to pick an antidepressant. Not all 12-step meetings are alike; 50,000 AA meetings are held every week in the United States (Box 1).^1-7 Recognizing the differences between the groups in your area will help you guide your patients to the best match.

In prescribing a 12-step program, consider these six patient factors: socioeconomic status, gender, age, attitude towards spirituality, smoking status, and drug of choice.

Box 1

Socioeconomic status

Matching patients with meetings according to socioeconomic status is not elitist—it’s pragmatic. Patients generally feel most comfortable and relate most readily at meetings where they feel they have something in common with the other members. For example, when a newly recovering middle-class alcoholic visits an AA group that is frequented by homeless and unemployed alcoholics, chances are that he will become more ambivalent about attending meetings. After all, he was never “that bad.”

A good practice is to give your patients an up-to-date 12-step meeting directory (Box 2). Suggest that they identify the meetings where they think they will feel most comfortable, based on the neighborhoods in which they are held.

Patients in early recovery often are terrified of encountering someone they know at a 12-step meeting. One strategy for patients concerned about protecting their anonymity—as many are—is to attend meetings outside their own neighborhoods but still in areas that match their socioeconomic status. Similarly, referring patients to meetings that are “closed to members only” might reduce their concerns about exposure.

Once a patient has connected with a 12-step program, matching by socioeconomic status becomes less important. Many begin to see similarities between themselves and other addicted individuals from all walks of life. In the beginning, however, similarities attract.

Your patient’s gender

Though women were once a small minority in AA and Narcotics Anonymous (NA), today they make up about one-third of AA’s membership and more than 40% of NA.⁸ One factor that may have boosted the number of women attending 12-step programs is the increased availability of women-only meetings.

Most cities have women-only meetings, and they generally will be a good place for your female patients to begin. Evidence indicates that gender-specific treatment enhances treatment outcomes.^9,10 Women-only meetings tend to be smaller than mixed groups, and the senior members are often particularly willing to welcome newcomers.

Although it is severely frowned upon, the phenomenon of AA or NA members attempting to become romantically or sexually involved with a newcomer is common enough that 12-step members have coined a term for it: “13-stepping.” Newly recovering patients are often emotionally vulnerable and at risk of becoming enmeshed in a potentially destructive relationship. Beginning recovery in gender-specific meetings helps to reduce this risk.

Your patient’s age

A 12-step meeting dominated by people with gray, blue, or no hair can quickly put off teens and young adults in early recovery. Though these meetings with older members are likely to include persons who have achieved long-term and healthy recovery (making such meetings ideal territory for finding a sponsor), finding peers of a similar age is also important.

Meetings intended for young people are identified in 12-step meeting directories, but many of these “young peoples’ ” meetings have a preponderance of members older than 30—quite ancient by a 16-year-old’s standards. Conversely, some generic 12-step meetings might have a cadre of teenagers that attend regularly—at least for a while.

In AA and NA, teens and young adults tend to travel in nomadic packs, linger for a few months, then move on. For this reason, having contacts familiar with the characteristics of local meetings can be invaluable as you try to match a younger patient with a 12-step meeting.

Attitude toward spirituality

One of patients’ most common complaints about 12-step meetings is their surprise at how “religious” the programs are. Insiders are quick to point out that 12-step programs are “spiritual” and not “religious,” but the distinction is moot to patients who are uneasy with this aspect of meetings. The talk about “God as I understand Him,” the opening and closing of meetings with prayers, and the generous adoption of Judeo-Christian practices can rub agnostic, atheistic, and otherwise spiritually indifferent patients the wrong way.

To protect your patients from being blind-sided, review with them some of the spiritual practices employed in 12-step programs before they attend their first meeting:

• Meetings begin with reading the Twelve Steps (Box 3) and other 12-step literature; all readings are peppered with spiritually-loaded words such as “God,” “Higher Power,” “prayer,” and “meditation.”
• Meetings end with a prayer in which the group stands and holds hands (in AA) or links their arms in a huddle (NA). [I advise patients who might find this activity intolerable to duck out to the rest room 5 minutes before the meeting ends.]
• Group leaders typically collect donations by passing the basket.

Certain meetings have a particularly heavy spiritual focus and might be appropriately prescribed for patients hungering for spiritual growth. But for patients who have had toxic encounters with religion or otherwise are ill-at-ease with spirituality or religious matters, starting out at one of the more spiritually hardcore 12-step meetings could be overwhelming. While your 12-step contact person is your best guide in these matters, the following points also apply:

• Meetings listed as “11th Step” or “God as I understand Him” meetings will have a strong spiritual focus.
• Meetings held on Sunday mornings often have the express purpose of focusing on spirituality.
• “Step” meetings generally have a more spiritual focus, as 11 of the 12 steps are aimed at eliciting a “spiritual awakening.”
• “Speaker” or “topic discussion” meetings tend to have a less spiritual focus, though this will vary with the meeting chairperson’s preferences.
• “Beginners” meetings, when available, are intended for new members and devote more time to helping the newcomer understand the 12-step approach to spirituality.

Box 2

Box 3

AA’s main text, the so-called “Big Book” (its real title is: Alcoholics Anonymous⁷) has a chapter titled, “We Agnostics.” AA has many long-time members who have found support in the fellowship but never “found God” or a belief in a higher power other than the fellowship itself. These secular 12-step members demonstrate one of the many ironies of AA and NA—that spiritual fellowships can work even for individuals who reject spirituality.

Patients who resist spirituality are advised to “take what you can use” from the fellowship and “leave the rest.” While 12-step members will propose that the newcomer keep an open mind about spirituality, patients should also be assured that a seat is always waiting for them, regardless.

Whether your patient smokes

Most 12-step meetings today are smoke-free, not because of enlightenment within the fellowships but because meetings are usually held in churches, synagogues, and health care facilities where smoking is banned. The perception that attending 12-step meetings can be harmful to your health is out-of-date. Nonetheless, because most meetings have banned smoking, the few in which smoking is allowed are thick with smoke.

In general, 12-step clubhouses are among the holdouts where smoking is allowed during and after meetings. A clubhouse is typically a storefront rented or acquired by AA/NA members where meetings are held around the clock. Given the evidence that quitting smoking may improve overall health,^10,11 patients should be encouraged to begin their involvement in smoke-free fellowships, which are identified in 12-step directories.

Your patient’s drug of choice

As its name implies, AA is intended for persons who desire to stop drinking. In practice, however, much of AA’s membership is addicted to more than one substance, and—in some cases—the drug of choice might not be alcohol.

Narcotics Anonymous—contrary to what its name implies—is for individuals addicted to any drug, not just narcotics. Patients generally should be advised to join the fellowship (AA or NA) that best matches their substance use history. There is, however, at least one exception that might best be illustrated with an example:

After I recommended NA meetings to a middle-class nurse addicted to analgesics, she returned for her next appointment quite angry. She attended three different NA meetings, and “all of the members were either heroin or crack cocaine addicts.” It seemed to her that all of them were on probation or parole. She was very uncomfortable throughout the meetings and upset with my recommendation.

In matching patients with meetings, socioeconomic and cultural factors take precedence over biochemistry. At the neuronal level, a nurse addicted to analgesics has a lot in common with a heroin addict, but her ability to relate to another recovering person—particularly in early recovery—may be limited. Arguing with my patient or countering that other nurses were probably at the meetings she attended would not have eased her reluctance to return to NA or helped our therapeutic alliance.

NA meetings are generally attended by individuals addicted to illicit drugs: amphetamines, crack cocaine, cannabis, and heroin. In larger cities, other 12-step fellowships may focus on specific drugs, such as cocaine, but these are rare. Just as individuals addicted to prescription narcotics are a minority in the treatment population, they are also a minority in NA.

For this reason, our prior recommendation—to match patients to meetings based on socioeconomic status—applies. It’s good policy to recommend that patients addicted to prescription medications try both AA and NA meetings and decide where they feel most comfortable.

The third tradition of AA states, “the only requirement for AA membership is a desire to stop drinking.” Though a purist might suggest that our analgesics-dependent nurse should join NA, her need to connect culturally with similar persons in recovery argues strongly for her to blend in at open AA meetings. A social drinker who never fulfilled the diagnostic criteria for alcohol dependence, she will have a better chance of abstaining from analgesics if she abstains from alcohol as well. For this reason, she should qualify for AA membership because she does, in fact, have “a desire to stop drinking.”

Some professionals addicted to prescription drugs will feel at home in NA meetings, whereas others will react as my patient did. Having access to a 12-step contact person who knows about the demographics of local NA meetings can help you make the best patient/meeting match.

Related resources

• Alcoholics Anonymous. www.alcoholics-anonymous.org
• Narcotics Anonymous. www.na.org
• Alanon-Alateen. www.al-anon.org

Attending the wrong 12-step meeting can turn off some patients, despite the substance abuse treatment support offered by Alcoholics Anonymous (AA) and similar programs. Because of the stigma associated with alcohol or drug addiction, most patients are ambivalent at best about attending their first 12-step meetings. Feeling “out of place”—the most common turn-off—can transform this ambivalence into adamant resistance.

Simply advising an addicted patient to “call AA” is tantamount to giving a depressed patient a copy of the Physicians’ Desk Reference and telling him or her to pick an antidepressant. Not all 12-step meetings are alike; 50,000 AA meetings are held every week in the United States (Box 1).^1-7 Recognizing the differences between the groups in your area will help you guide your patients to the best match.

In prescribing a 12-step program, consider these six patient factors: socioeconomic status, gender, age, attitude towards spirituality, smoking status, and drug of choice.

Box 1

Socioeconomic status

Matching patients with meetings according to socioeconomic status is not elitist—it’s pragmatic. Patients generally feel most comfortable and relate most readily at meetings where they feel they have something in common with the other members. For example, when a newly recovering middle-class alcoholic visits an AA group that is frequented by homeless and unemployed alcoholics, chances are that he will become more ambivalent about attending meetings. After all, he was never “that bad.”

A good practice is to give your patients an up-to-date 12-step meeting directory (Box 2). Suggest that they identify the meetings where they think they will feel most comfortable, based on the neighborhoods in which they are held.

Patients in early recovery often are terrified of encountering someone they know at a 12-step meeting. One strategy for patients concerned about protecting their anonymity—as many are—is to attend meetings outside their own neighborhoods but still in areas that match their socioeconomic status. Similarly, referring patients to meetings that are “closed to members only” might reduce their concerns about exposure.

Once a patient has connected with a 12-step program, matching by socioeconomic status becomes less important. Many begin to see similarities between themselves and other addicted individuals from all walks of life. In the beginning, however, similarities attract.

Your patient’s gender

Though women were once a small minority in AA and Narcotics Anonymous (NA), today they make up about one-third of AA’s membership and more than 40% of NA.⁸ One factor that may have boosted the number of women attending 12-step programs is the increased availability of women-only meetings.

Most cities have women-only meetings, and they generally will be a good place for your female patients to begin. Evidence indicates that gender-specific treatment enhances treatment outcomes.^9,10 Women-only meetings tend to be smaller than mixed groups, and the senior members are often particularly willing to welcome newcomers.

Although it is severely frowned upon, the phenomenon of AA or NA members attempting to become romantically or sexually involved with a newcomer is common enough that 12-step members have coined a term for it: “13-stepping.” Newly recovering patients are often emotionally vulnerable and at risk of becoming enmeshed in a potentially destructive relationship. Beginning recovery in gender-specific meetings helps to reduce this risk.

Your patient’s age

A 12-step meeting dominated by people with gray, blue, or no hair can quickly put off teens and young adults in early recovery. Though these meetings with older members are likely to include persons who have achieved long-term and healthy recovery (making such meetings ideal territory for finding a sponsor), finding peers of a similar age is also important.

Meetings intended for young people are identified in 12-step meeting directories, but many of these “young peoples’ ” meetings have a preponderance of members older than 30—quite ancient by a 16-year-old’s standards. Conversely, some generic 12-step meetings might have a cadre of teenagers that attend regularly—at least for a while.

In AA and NA, teens and young adults tend to travel in nomadic packs, linger for a few months, then move on. For this reason, having contacts familiar with the characteristics of local meetings can be invaluable as you try to match a younger patient with a 12-step meeting.

Attitude toward spirituality

One of patients’ most common complaints about 12-step meetings is their surprise at how “religious” the programs are. Insiders are quick to point out that 12-step programs are “spiritual” and not “religious,” but the distinction is moot to patients who are uneasy with this aspect of meetings. The talk about “God as I understand Him,” the opening and closing of meetings with prayers, and the generous adoption of Judeo-Christian practices can rub agnostic, atheistic, and otherwise spiritually indifferent patients the wrong way.

To protect your patients from being blind-sided, review with them some of the spiritual practices employed in 12-step programs before they attend their first meeting:

• Meetings begin with reading the Twelve Steps (Box 3) and other 12-step literature; all readings are peppered with spiritually-loaded words such as “God,” “Higher Power,” “prayer,” and “meditation.”
• Meetings end with a prayer in which the group stands and holds hands (in AA) or links their arms in a huddle (NA). [I advise patients who might find this activity intolerable to duck out to the rest room 5 minutes before the meeting ends.]
• Group leaders typically collect donations by passing the basket.

Certain meetings have a particularly heavy spiritual focus and might be appropriately prescribed for patients hungering for spiritual growth. But for patients who have had toxic encounters with religion or otherwise are ill-at-ease with spirituality or religious matters, starting out at one of the more spiritually hardcore 12-step meetings could be overwhelming. While your 12-step contact person is your best guide in these matters, the following points also apply:

• Meetings listed as “11th Step” or “God as I understand Him” meetings will have a strong spiritual focus.
• Meetings held on Sunday mornings often have the express purpose of focusing on spirituality.
• “Step” meetings generally have a more spiritual focus, as 11 of the 12 steps are aimed at eliciting a “spiritual awakening.”
• “Speaker” or “topic discussion” meetings tend to have a less spiritual focus, though this will vary with the meeting chairperson’s preferences.
• “Beginners” meetings, when available, are intended for new members and devote more time to helping the newcomer understand the 12-step approach to spirituality.

Box 2

Box 3

AA’s main text, the so-called “Big Book” (its real title is: Alcoholics Anonymous⁷) has a chapter titled, “We Agnostics.” AA has many long-time members who have found support in the fellowship but never “found God” or a belief in a higher power other than the fellowship itself. These secular 12-step members demonstrate one of the many ironies of AA and NA—that spiritual fellowships can work even for individuals who reject spirituality.

Patients who resist spirituality are advised to “take what you can use” from the fellowship and “leave the rest.” While 12-step members will propose that the newcomer keep an open mind about spirituality, patients should also be assured that a seat is always waiting for them, regardless.

Whether your patient smokes

Most 12-step meetings today are smoke-free, not because of enlightenment within the fellowships but because meetings are usually held in churches, synagogues, and health care facilities where smoking is banned. The perception that attending 12-step meetings can be harmful to your health is out-of-date. Nonetheless, because most meetings have banned smoking, the few in which smoking is allowed are thick with smoke.

In general, 12-step clubhouses are among the holdouts where smoking is allowed during and after meetings. A clubhouse is typically a storefront rented or acquired by AA/NA members where meetings are held around the clock. Given the evidence that quitting smoking may improve overall health,^10,11 patients should be encouraged to begin their involvement in smoke-free fellowships, which are identified in 12-step directories.

Your patient’s drug of choice

As its name implies, AA is intended for persons who desire to stop drinking. In practice, however, much of AA’s membership is addicted to more than one substance, and—in some cases—the drug of choice might not be alcohol.

Narcotics Anonymous—contrary to what its name implies—is for individuals addicted to any drug, not just narcotics. Patients generally should be advised to join the fellowship (AA or NA) that best matches their substance use history. There is, however, at least one exception that might best be illustrated with an example:

After I recommended NA meetings to a middle-class nurse addicted to analgesics, she returned for her next appointment quite angry. She attended three different NA meetings, and “all of the members were either heroin or crack cocaine addicts.” It seemed to her that all of them were on probation or parole. She was very uncomfortable throughout the meetings and upset with my recommendation.

In matching patients with meetings, socioeconomic and cultural factors take precedence over biochemistry. At the neuronal level, a nurse addicted to analgesics has a lot in common with a heroin addict, but her ability to relate to another recovering person—particularly in early recovery—may be limited. Arguing with my patient or countering that other nurses were probably at the meetings she attended would not have eased her reluctance to return to NA or helped our therapeutic alliance.

NA meetings are generally attended by individuals addicted to illicit drugs: amphetamines, crack cocaine, cannabis, and heroin. In larger cities, other 12-step fellowships may focus on specific drugs, such as cocaine, but these are rare. Just as individuals addicted to prescription narcotics are a minority in the treatment population, they are also a minority in NA.

For this reason, our prior recommendation—to match patients to meetings based on socioeconomic status—applies. It’s good policy to recommend that patients addicted to prescription medications try both AA and NA meetings and decide where they feel most comfortable.

The third tradition of AA states, “the only requirement for AA membership is a desire to stop drinking.” Though a purist might suggest that our analgesics-dependent nurse should join NA, her need to connect culturally with similar persons in recovery argues strongly for her to blend in at open AA meetings. A social drinker who never fulfilled the diagnostic criteria for alcohol dependence, she will have a better chance of abstaining from analgesics if she abstains from alcohol as well. For this reason, she should qualify for AA membership because she does, in fact, have “a desire to stop drinking.”

Some professionals addicted to prescription drugs will feel at home in NA meetings, whereas others will react as my patient did. Having access to a 12-step contact person who knows about the demographics of local NA meetings can help you make the best patient/meeting match.

Related resources

• Alcoholics Anonymous. www.alcoholics-anonymous.org
• Narcotics Anonymous. www.na.org
• Alanon-Alateen. www.al-anon.org

Attending the wrong 12-step meeting can turn off some patients, despite the substance abuse treatment support offered by Alcoholics Anonymous (AA) and similar programs. Because of the stigma associated with alcohol or drug addiction, most patients are ambivalent at best about attending their first 12-step meetings. Feeling “out of place”—the most common turn-off—can transform this ambivalence into adamant resistance.

Simply advising an addicted patient to “call AA” is tantamount to giving a depressed patient a copy of the Physicians’ Desk Reference and telling him or her to pick an antidepressant. Not all 12-step meetings are alike; 50,000 AA meetings are held every week in the United States (Box 1).^1-7 Recognizing the differences between the groups in your area will help you guide your patients to the best match.

In prescribing a 12-step program, consider these six patient factors: socioeconomic status, gender, age, attitude towards spirituality, smoking status, and drug of choice.

Box 1

Socioeconomic status

Matching patients with meetings according to socioeconomic status is not elitist—it’s pragmatic. Patients generally feel most comfortable and relate most readily at meetings where they feel they have something in common with the other members. For example, when a newly recovering middle-class alcoholic visits an AA group that is frequented by homeless and unemployed alcoholics, chances are that he will become more ambivalent about attending meetings. After all, he was never “that bad.”

A good practice is to give your patients an up-to-date 12-step meeting directory (Box 2). Suggest that they identify the meetings where they think they will feel most comfortable, based on the neighborhoods in which they are held.

Patients in early recovery often are terrified of encountering someone they know at a 12-step meeting. One strategy for patients concerned about protecting their anonymity—as many are—is to attend meetings outside their own neighborhoods but still in areas that match their socioeconomic status. Similarly, referring patients to meetings that are “closed to members only” might reduce their concerns about exposure.

Once a patient has connected with a 12-step program, matching by socioeconomic status becomes less important. Many begin to see similarities between themselves and other addicted individuals from all walks of life. In the beginning, however, similarities attract.

Your patient’s gender

Though women were once a small minority in AA and Narcotics Anonymous (NA), today they make up about one-third of AA’s membership and more than 40% of NA.⁸ One factor that may have boosted the number of women attending 12-step programs is the increased availability of women-only meetings.

Most cities have women-only meetings, and they generally will be a good place for your female patients to begin. Evidence indicates that gender-specific treatment enhances treatment outcomes.^9,10 Women-only meetings tend to be smaller than mixed groups, and the senior members are often particularly willing to welcome newcomers.

Although it is severely frowned upon, the phenomenon of AA or NA members attempting to become romantically or sexually involved with a newcomer is common enough that 12-step members have coined a term for it: “13-stepping.” Newly recovering patients are often emotionally vulnerable and at risk of becoming enmeshed in a potentially destructive relationship. Beginning recovery in gender-specific meetings helps to reduce this risk.

Your patient’s age

A 12-step meeting dominated by people with gray, blue, or no hair can quickly put off teens and young adults in early recovery. Though these meetings with older members are likely to include persons who have achieved long-term and healthy recovery (making such meetings ideal territory for finding a sponsor), finding peers of a similar age is also important.

Meetings intended for young people are identified in 12-step meeting directories, but many of these “young peoples’ ” meetings have a preponderance of members older than 30—quite ancient by a 16-year-old’s standards. Conversely, some generic 12-step meetings might have a cadre of teenagers that attend regularly—at least for a while.

In AA and NA, teens and young adults tend to travel in nomadic packs, linger for a few months, then move on. For this reason, having contacts familiar with the characteristics of local meetings can be invaluable as you try to match a younger patient with a 12-step meeting.

Attitude toward spirituality

One of patients’ most common complaints about 12-step meetings is their surprise at how “religious” the programs are. Insiders are quick to point out that 12-step programs are “spiritual” and not “religious,” but the distinction is moot to patients who are uneasy with this aspect of meetings. The talk about “God as I understand Him,” the opening and closing of meetings with prayers, and the generous adoption of Judeo-Christian practices can rub agnostic, atheistic, and otherwise spiritually indifferent patients the wrong way.

To protect your patients from being blind-sided, review with them some of the spiritual practices employed in 12-step programs before they attend their first meeting:

• Meetings begin with reading the Twelve Steps (Box 3) and other 12-step literature; all readings are peppered with spiritually-loaded words such as “God,” “Higher Power,” “prayer,” and “meditation.”
• Meetings end with a prayer in which the group stands and holds hands (in AA) or links their arms in a huddle (NA). [I advise patients who might find this activity intolerable to duck out to the rest room 5 minutes before the meeting ends.]
• Group leaders typically collect donations by passing the basket.

Certain meetings have a particularly heavy spiritual focus and might be appropriately prescribed for patients hungering for spiritual growth. But for patients who have had toxic encounters with religion or otherwise are ill-at-ease with spirituality or religious matters, starting out at one of the more spiritually hardcore 12-step meetings could be overwhelming. While your 12-step contact person is your best guide in these matters, the following points also apply:

• Meetings listed as “11th Step” or “God as I understand Him” meetings will have a strong spiritual focus.
• Meetings held on Sunday mornings often have the express purpose of focusing on spirituality.
• “Step” meetings generally have a more spiritual focus, as 11 of the 12 steps are aimed at eliciting a “spiritual awakening.”
• “Speaker” or “topic discussion” meetings tend to have a less spiritual focus, though this will vary with the meeting chairperson’s preferences.
• “Beginners” meetings, when available, are intended for new members and devote more time to helping the newcomer understand the 12-step approach to spirituality.

Box 2

Box 3

AA’s main text, the so-called “Big Book” (its real title is: Alcoholics Anonymous⁷) has a chapter titled, “We Agnostics.” AA has many long-time members who have found support in the fellowship but never “found God” or a belief in a higher power other than the fellowship itself. These secular 12-step members demonstrate one of the many ironies of AA and NA—that spiritual fellowships can work even for individuals who reject spirituality.

Patients who resist spirituality are advised to “take what you can use” from the fellowship and “leave the rest.” While 12-step members will propose that the newcomer keep an open mind about spirituality, patients should also be assured that a seat is always waiting for them, regardless.

Whether your patient smokes

Most 12-step meetings today are smoke-free, not because of enlightenment within the fellowships but because meetings are usually held in churches, synagogues, and health care facilities where smoking is banned. The perception that attending 12-step meetings can be harmful to your health is out-of-date. Nonetheless, because most meetings have banned smoking, the few in which smoking is allowed are thick with smoke.

In general, 12-step clubhouses are among the holdouts where smoking is allowed during and after meetings. A clubhouse is typically a storefront rented or acquired by AA/NA members where meetings are held around the clock. Given the evidence that quitting smoking may improve overall health,^10,11 patients should be encouraged to begin their involvement in smoke-free fellowships, which are identified in 12-step directories.

Your patient’s drug of choice

As its name implies, AA is intended for persons who desire to stop drinking. In practice, however, much of AA’s membership is addicted to more than one substance, and—in some cases—the drug of choice might not be alcohol.

Narcotics Anonymous—contrary to what its name implies—is for individuals addicted to any drug, not just narcotics. Patients generally should be advised to join the fellowship (AA or NA) that best matches their substance use history. There is, however, at least one exception that might best be illustrated with an example:

After I recommended NA meetings to a middle-class nurse addicted to analgesics, she returned for her next appointment quite angry. She attended three different NA meetings, and “all of the members were either heroin or crack cocaine addicts.” It seemed to her that all of them were on probation or parole. She was very uncomfortable throughout the meetings and upset with my recommendation.

In matching patients with meetings, socioeconomic and cultural factors take precedence over biochemistry. At the neuronal level, a nurse addicted to analgesics has a lot in common with a heroin addict, but her ability to relate to another recovering person—particularly in early recovery—may be limited. Arguing with my patient or countering that other nurses were probably at the meetings she attended would not have eased her reluctance to return to NA or helped our therapeutic alliance.

NA meetings are generally attended by individuals addicted to illicit drugs: amphetamines, crack cocaine, cannabis, and heroin. In larger cities, other 12-step fellowships may focus on specific drugs, such as cocaine, but these are rare. Just as individuals addicted to prescription narcotics are a minority in the treatment population, they are also a minority in NA.

For this reason, our prior recommendation—to match patients to meetings based on socioeconomic status—applies. It’s good policy to recommend that patients addicted to prescription medications try both AA and NA meetings and decide where they feel most comfortable.

The third tradition of AA states, “the only requirement for AA membership is a desire to stop drinking.” Though a purist might suggest that our analgesics-dependent nurse should join NA, her need to connect culturally with similar persons in recovery argues strongly for her to blend in at open AA meetings. A social drinker who never fulfilled the diagnostic criteria for alcohol dependence, she will have a better chance of abstaining from analgesics if she abstains from alcohol as well. For this reason, she should qualify for AA membership because she does, in fact, have “a desire to stop drinking.”

Some professionals addicted to prescription drugs will feel at home in NA meetings, whereas others will react as my patient did. Having access to a 12-step contact person who knows about the demographics of local NA meetings can help you make the best patient/meeting match.

Related resources

• Alcoholics Anonymous. www.alcoholics-anonymous.org
• Narcotics Anonymous. www.na.org
• Alanon-Alateen. www.al-anon.org

Attending the wrong 12-step meeting can turn off some patients, despite the substance abuse treatment support offered by Alcoholics Anonymous (AA) and similar programs. Because of the stigma associated with alcohol or drug addiction, most patients are ambivalent at best about attending their first 12-step meetings. Feeling “out of place”—the most common turn-off—can transform this ambivalence into adamant resistance.

Simply advising an addicted patient to “call AA” is tantamount to giving a depressed patient a copy of the Physicians’ Desk Reference and telling him or her to pick an antidepressant. Not all 12-step meetings are alike; 50,000 AA meetings are held every week in the United States (Box 1).^1-7 Recognizing the differences between the groups in your area will help you guide your patients to the best match.

In prescribing a 12-step program, consider these six patient factors: socioeconomic status, gender, age, attitude towards spirituality, smoking status, and drug of choice.

Box 1

Socioeconomic status

Matching patients with meetings according to socioeconomic status is not elitist—it’s pragmatic. Patients generally feel most comfortable and relate most readily at meetings where they feel they have something in common with the other members. For example, when a newly recovering middle-class alcoholic visits an AA group that is frequented by homeless and unemployed alcoholics, chances are that he will become more ambivalent about attending meetings. After all, he was never “that bad.”

A good practice is to give your patients an up-to-date 12-step meeting directory (Box 2). Suggest that they identify the meetings where they think they will feel most comfortable, based on the neighborhoods in which they are held.

Patients in early recovery often are terrified of encountering someone they know at a 12-step meeting. One strategy for patients concerned about protecting their anonymity—as many are—is to attend meetings outside their own neighborhoods but still in areas that match their socioeconomic status. Similarly, referring patients to meetings that are “closed to members only” might reduce their concerns about exposure.

Once a patient has connected with a 12-step program, matching by socioeconomic status becomes less important. Many begin to see similarities between themselves and other addicted individuals from all walks of life. In the beginning, however, similarities attract.

Your patient’s gender

Though women were once a small minority in AA and Narcotics Anonymous (NA), today they make up about one-third of AA’s membership and more than 40% of NA.⁸ One factor that may have boosted the number of women attending 12-step programs is the increased availability of women-only meetings.

Most cities have women-only meetings, and they generally will be a good place for your female patients to begin. Evidence indicates that gender-specific treatment enhances treatment outcomes.^9,10 Women-only meetings tend to be smaller than mixed groups, and the senior members are often particularly willing to welcome newcomers.

Although it is severely frowned upon, the phenomenon of AA or NA members attempting to become romantically or sexually involved with a newcomer is common enough that 12-step members have coined a term for it: “13-stepping.” Newly recovering patients are often emotionally vulnerable and at risk of becoming enmeshed in a potentially destructive relationship. Beginning recovery in gender-specific meetings helps to reduce this risk.

Your patient’s age

A 12-step meeting dominated by people with gray, blue, or no hair can quickly put off teens and young adults in early recovery. Though these meetings with older members are likely to include persons who have achieved long-term and healthy recovery (making such meetings ideal territory for finding a sponsor), finding peers of a similar age is also important.

Meetings intended for young people are identified in 12-step meeting directories, but many of these “young peoples’ ” meetings have a preponderance of members older than 30—quite ancient by a 16-year-old’s standards. Conversely, some generic 12-step meetings might have a cadre of teenagers that attend regularly—at least for a while.

In AA and NA, teens and young adults tend to travel in nomadic packs, linger for a few months, then move on. For this reason, having contacts familiar with the characteristics of local meetings can be invaluable as you try to match a younger patient with a 12-step meeting.

Attitude toward spirituality

One of patients’ most common complaints about 12-step meetings is their surprise at how “religious” the programs are. Insiders are quick to point out that 12-step programs are “spiritual” and not “religious,” but the distinction is moot to patients who are uneasy with this aspect of meetings. The talk about “God as I understand Him,” the opening and closing of meetings with prayers, and the generous adoption of Judeo-Christian practices can rub agnostic, atheistic, and otherwise spiritually indifferent patients the wrong way.

To protect your patients from being blind-sided, review with them some of the spiritual practices employed in 12-step programs before they attend their first meeting:

• Meetings begin with reading the Twelve Steps (Box 3) and other 12-step literature; all readings are peppered with spiritually-loaded words such as “God,” “Higher Power,” “prayer,” and “meditation.”
• Meetings end with a prayer in which the group stands and holds hands (in AA) or links their arms in a huddle (NA). [I advise patients who might find this activity intolerable to duck out to the rest room 5 minutes before the meeting ends.]
• Group leaders typically collect donations by passing the basket.

Certain meetings have a particularly heavy spiritual focus and might be appropriately prescribed for patients hungering for spiritual growth. But for patients who have had toxic encounters with religion or otherwise are ill-at-ease with spirituality or religious matters, starting out at one of the more spiritually hardcore 12-step meetings could be overwhelming. While your 12-step contact person is your best guide in these matters, the following points also apply:

• Meetings listed as “11th Step” or “God as I understand Him” meetings will have a strong spiritual focus.
• Meetings held on Sunday mornings often have the express purpose of focusing on spirituality.
• “Step” meetings generally have a more spiritual focus, as 11 of the 12 steps are aimed at eliciting a “spiritual awakening.”
• “Speaker” or “topic discussion” meetings tend to have a less spiritual focus, though this will vary with the meeting chairperson’s preferences.
• “Beginners” meetings, when available, are intended for new members and devote more time to helping the newcomer understand the 12-step approach to spirituality.

Box 2

Box 3

AA’s main text, the so-called “Big Book” (its real title is: Alcoholics Anonymous⁷) has a chapter titled, “We Agnostics.” AA has many long-time members who have found support in the fellowship but never “found God” or a belief in a higher power other than the fellowship itself. These secular 12-step members demonstrate one of the many ironies of AA and NA—that spiritual fellowships can work even for individuals who reject spirituality.

Patients who resist spirituality are advised to “take what you can use” from the fellowship and “leave the rest.” While 12-step members will propose that the newcomer keep an open mind about spirituality, patients should also be assured that a seat is always waiting for them, regardless.

Whether your patient smokes

Most 12-step meetings today are smoke-free, not because of enlightenment within the fellowships but because meetings are usually held in churches, synagogues, and health care facilities where smoking is banned. The perception that attending 12-step meetings can be harmful to your health is out-of-date. Nonetheless, because most meetings have banned smoking, the few in which smoking is allowed are thick with smoke.

In general, 12-step clubhouses are among the holdouts where smoking is allowed during and after meetings. A clubhouse is typically a storefront rented or acquired by AA/NA members where meetings are held around the clock. Given the evidence that quitting smoking may improve overall health,^10,11 patients should be encouraged to begin their involvement in smoke-free fellowships, which are identified in 12-step directories.

Your patient’s drug of choice

As its name implies, AA is intended for persons who desire to stop drinking. In practice, however, much of AA’s membership is addicted to more than one substance, and—in some cases—the drug of choice might not be alcohol.

Narcotics Anonymous—contrary to what its name implies—is for individuals addicted to any drug, not just narcotics. Patients generally should be advised to join the fellowship (AA or NA) that best matches their substance use history. There is, however, at least one exception that might best be illustrated with an example:

After I recommended NA meetings to a middle-class nurse addicted to analgesics, she returned for her next appointment quite angry. She attended three different NA meetings, and “all of the members were either heroin or crack cocaine addicts.” It seemed to her that all of them were on probation or parole. She was very uncomfortable throughout the meetings and upset with my recommendation.

In matching patients with meetings, socioeconomic and cultural factors take precedence over biochemistry. At the neuronal level, a nurse addicted to analgesics has a lot in common with a heroin addict, but her ability to relate to another recovering person—particularly in early recovery—may be limited. Arguing with my patient or countering that other nurses were probably at the meetings she attended would not have eased her reluctance to return to NA or helped our therapeutic alliance.

NA meetings are generally attended by individuals addicted to illicit drugs: amphetamines, crack cocaine, cannabis, and heroin. In larger cities, other 12-step fellowships may focus on specific drugs, such as cocaine, but these are rare. Just as individuals addicted to prescription narcotics are a minority in the treatment population, they are also a minority in NA.

For this reason, our prior recommendation—to match patients to meetings based on socioeconomic status—applies. It’s good policy to recommend that patients addicted to prescription medications try both AA and NA meetings and decide where they feel most comfortable.

The third tradition of AA states, “the only requirement for AA membership is a desire to stop drinking.” Though a purist might suggest that our analgesics-dependent nurse should join NA, her need to connect culturally with similar persons in recovery argues strongly for her to blend in at open AA meetings. A social drinker who never fulfilled the diagnostic criteria for alcohol dependence, she will have a better chance of abstaining from analgesics if she abstains from alcohol as well. For this reason, she should qualify for AA membership because she does, in fact, have “a desire to stop drinking.”

Some professionals addicted to prescription drugs will feel at home in NA meetings, whereas others will react as my patient did. Having access to a 12-step contact person who knows about the demographics of local NA meetings can help you make the best patient/meeting match.

Related resources

• Alcoholics Anonymous. www.alcoholics-anonymous.org
• Narcotics Anonymous. www.na.org
• Alanon-Alateen. www.al-anon.org

Outpatient treatment of substance abuse is changing as research and experience teach us more about the nature of addictive illness and the principles of recovery. The recommended approach now emphasizes ease of access, chronic rather than acute treatment, and collaboration rather than confrontation.

As psychiatrists, we should be familiar with these changes, so that we can offer our addicted patients effective treatment and referrals. In particular, those of us who lead multidisciplinary teams in mental health clinics and outpatient programs need strategies that will help us make sound clinical decisions on detoxification, medical or psychiatric stabilization, and rehabilitation goals.

A new protocol that addresses these needs is being developed by a consensus panel of the Center for Substance Abuse and Treatment (Box 1).^1,2 Two of us (RFF, RR) are members of that panel, and we all are recognized experts in the outpatient treatment of addicted individuals, with combined experience of more than 70 years. Based on available evidence and expert opinion, we offer you 12 principles of outpatient substance dependence treatment that can help you achieve the most favorable results (Table 1).

Box 1

Principle 1: Open the doors wider

Outpatient clinics were once considered inappropriate for addicted individuals with significant psychosocial problems (such as homelessness) or co-occurring psychiatric disorders. Successful outpatient treatment was thought possible only for high-functioning, employed addicts who were free of significant psychiatric comorbidity.

Today, it is accepted that outpatients with a wide range of biopsychosocial problems can be effectively treated IF they receive case management and housing support and their co-occurring medical and psychiatric conditions are stabilized.

Efforts to ease the addicted patient into treatment should begin the moment a potential patient or family member seeks help. The pleasure that substance abusers derive from drug use makes them typically ambivalent about stopping their compulsive behaviors, and delays or obstacles to admission lead to “no shows” and drop-outs.³ Admissions increase when patients are given appointments the day they call for help.

From the initial outpatient encounter, the patient should feel like a welcomed participant who is responsible for his or her recovery. Access to outpatient programs increases when:

• child-care assistance is provided as needed;
• hours of operation are designed for the patient’s (rather than the staff’s) convenience;
• transportation assistance is provided, particularly for adolescents;
• the treatment plan is flexible and individualized to meet each patient’s specific needs.

Principle 2: Do a comprehensive initial evaluation

The open-door approach is most successful when the psychiatrist performs a comprehensive initial psychiatric and medical evaluation and works closely with a specialized treatment team. The initial medical and psychiatric evaluation is beyond the scope of this article and has been previously reviewed.⁴ Determining the need for medical detoxification is a priority during this phase of treatment.

Drug use patterns The treating physician should maintain a high index of suspicion for conditions associated with drug use. Cocaine causes seizures and cardiac arrhythmias, as well as vasoconstriction that leads to tissue necrosis (i.e., myocardial infarction, stroke, spontaneous abortion, and renal failure). Alcohol abuse affects brain, liver, cardiac, and endocrine tissue. Heroin produces acute overdose through respiratory depression, and its IV route of administration increases the risk of AIDS, viral hepatitis, pneumonia, sepsis, and endocarditis.

Function Structured interviews such as the Addiction Severity Index (ASI)⁵ can be used to assess functional impairment. Because addicted patients may be reluctant to disclose sensitive personal information, it is important to collect collateral information from family and friends, laboratory tests, and medical records.

Psychiatric concerns Many psychiatric syndromes are caused by substance abuse. Cocaine intoxication is often associated with psychosis (paranoia, auditory and tactile hallucinations), panic anxiety, and aggressiveness, whereas cocaine withdrawal produces depressed mood. Depression is also highly associated with chronic alcohol and opiate dependence. Withdrawal from opioids, alcohol, and sedatives produces anxiety.

Patients with bipolar disorder, major depression, panic anxiety, and schizophrenia who present with co-occurring addiction require coordinated and simultaneous stabilization of their addictive and psychiatric disorders.

Table 1

12 PRINCIPLES OF EFFECTIVE OUTPATIENT ADDICTION TREATMENT

Principle 3: Build on existing motivation

That an addicted patient must “hit bottom” before successful treatment may begin is a common misconception. In truth, studies find similar outcomes in individuals who enter treatment voluntarily and those who are externally pressured or legally coerced.⁶ Regardless of patients’ motivation when they enter treatment, they are likely to alternate over time between being more and less motivated. For this reason, it is necessary to remind them why they sought treatment and to use existing external pressures.

For example, with the patient’s consent it would be valuable to maintain contact with a parole officer who mandated a patient’s substance-abuse treatment. Likewise, patients entering treatment under threat of divorce should be asked to consent to family contact and should receive family therapy. Families often provide useful clinical information and can exert powerful influence when the patient’s motivation wanes. A patient’s refusal to allow contact with family (or other important sources of collateral information) often represents resistance that should be explored clinically and addressed.

With open dialogue, resistance to treatment can be reduced with education, peer groups, and family therapy. Motivational enhancement and interviewing work described by Miller, Procaska, and DiClemente^7,8 is designed to reduce treatment resistance in a respectful and clinically effective manner while avoiding confrontation that might provoke dropout and relapse.

Principle 4: Forge a therapeutic alliance

A therapeutic alliance produces positive outcomes in substance-dependent outpatients.^9-11 A recent National Institute on Drug Abuse (NIDA) therapy manual notes that a therapeutic alliance exists when the patient perceives that:

• the clinician accepts and respects him or her;
• the patient’s problems can be overcome by working together with the clinician;
• the clinician understands what the patient is hoping to get out of treatment.¹²

Clinicians can help forge this therapeutic alliance by being active listeners, by being empathic and nonjudgmental, and by approaching treatment as an active collaboration.¹²

Principle 5: Make retention a priority

It is simple but true: you cannot treat a patient who has dropped out.

Treatment retention is associated with better outcomes^13,14 and is a key indicator of the performance of an outpatient treatment program. High drop-out rates are demoralizing to patients who remain in treatment and to the clinicians who must document so-called “3-day treatments.” Because admission and initial evaluation of patients is labor-intensive, premature attrition is costly and time-consuming. Strategies to increase retention are listed in Table 2.

Table 2

STRATEGIES TO RETAIN PATIENTS IN TREATMENT

Clinicians can improve retention by tolerating different rates of change and levels of motivation. Individuals adopt new behaviors at different rates. You might become frustrated when patients do not immediately “buy” a particular version of recovery. Patients, however, often drop out when they feel they are being “force-fed” recommendations for sacrifice and major lifestyle changes that make no sense to them (at least not at the moment).

Principle 6: Provide ongoing care

Addiction is a complex biopsychosocial problem that requires long-term treatment. Even after extended abstinence, substance abusers experience craving and are vulnerable to relapse.

Addicts often enter outpatient treatment with psychosocial, medical, and psychiatric problems. Transformation from active addiction to full functioning in society requires sustained and conscientious effort by the patient, support system, and treatment team. Like asthma, diabetes, and other chronic diseases, addiction requires ongoing care.¹⁵

Unlike other chronic conditions, however, addiction is pleasure-reinforced, and addicted individuals are particularly at risk for relapse. Ongoing care may interrupt a relapse or at least interrupt it sooner than if no ongoing treatment were provided.

Substance dependence treatment for less than 90 days is of little or no use, and treatment lasting significantly longer often is indicated, according to the NIDA.¹⁶ When patients complete an intensive treatment phase, they should be evaluated for readiness to transfer to less-intensive care, with gradual transition from several therapeutic contacts per week, to weekly contact, to semimonthly contact, and so on. The concept of “graduation” should clearly convey not an ending but a “commencement” or beginning, as it does in college.

Unfortunately, the long-term approach to substance dependence is undermined by managed care organizations’ insistence on brief treatments. Also, regulations that view addiction as an acute episode may require that patient charts be closed at the end of intensive treatment. Such failures to appreciate the chronic nature of addiction undermine access to treatment and service delivery and contribute to recidivism and medical, social, criminal, and economic consequences associated with active addiction.

Principle 7: Match services with treatment needs

Outcomes improve when treatment services meet individual needs.¹⁷ Medical, psychiatric, psychosocial, legal, and housing problems can distract patients from the work of therapy. It is important to match each patient’s problems and needs with appropriate treatment settings, interventions, and services, according to the NIDA’s Principles of Drug Addiction Treatment.¹⁶ Creating flexible, responsive programs means more work for the treatment team, but it enhances the quality of care.

Treating concomitant psychiatric illness often requires innovations in outpatient treatment programs. For example, psychiatrists must avoid undermining treatment by inappropriately prescribing addictive agents such as benzodiazepines. At the same time, drug counselors may benefit from education about the potential benefits of medications in treating co-occuring disorders and craving. Coordinated delivery of psychiatric and rehabilitative treatment requires open communication in regularly scheduled multidisciplinary team meetings.

Principle 8: Monitor abstinence

Routine urine drug screens, Breathalyzer tests—administered at least weekly— and/or other laboratory tests to confirm self-reported abstinence can improve treatment outcomes. Regular drug and alcohol monitoring provides an objective indicator of progress, serves as a deterrent, and can help motivate the patient to withstand drug urges.

Individuals attempting abstinence from one substance have better outcomes if they abstain from all addictive substances¹⁸ (although tobacco use is controversial and requires further research). Even so, patients often continue to use addictive substances during treatment. Patients struggling with abstinence should not be discharged from treatment programs for manifesting the symptoms for which they are seeking treatment.

Substance-dependent individuals progress at different rates during treatment, and creative strategies to enhance motivation and retention can ultimately produce positive results. Outpatient clinics should consider different treatment tracks for patients at different stages of readiness for recovery.

Box 2

Principle 9: Use 12-step and other community supports

Patients who participate in 12-step programs and treatments have better outcomes than those who do not.^19-21 Still, patients in early recovery may find it difficult to join community-based support groups, such as Alcoholics Anonymous (AA). Patients are often ambivalent about—or strongly opposed to—joining AA because of embarrassment, negative experiences, or inadequate preparation for joining a 12-step fellowship. Substance abusers who are ambivalent about recovery often dispute 12-step directives on total abstinence, sweeping lifestyle changes, and the need to “give up control” over treatment recommendations. Common issues in early recovery include:

• how to select a 12-step home group and a sponsor;
• how to overcome uneasiness associated with being in a 12-step group;
• how to address any discomfort the patient may feel with the religious nature of 12-step meetings.²²

Patients’ resistance to 12-step treatment should be explored and addressed. Sometimes all they need is encouragement and help in finding a sponsor. Those with more difficult concerns may need a different approach. For example, social phobia is common in alcoholics and can be exacerbated by 12-step meetings; symptoms often respond to beta-adrenergic blockade. Patients with schizophrenia and those with paranoid features often do poorly in 12-step treatment if their paranoid symptoms cannot be successfully managed.

Principle 10: Manage medications

To avoid drug interactions, all prescribers involved with the patient’s care should coordinate their medication management efforts. Many substance abusers suffer from co-occurring psychiatric conditions²³ for which psychiatric medications are standard treatment.^24,25 In addition, medical detoxification is often necessary for heroin, alcohol, and sedative/hypnotic-dependent individuals. These treatments, which are beyond the scope of this article, are best integrated with drug rehabilitation.

Various medications for addiction have been reported to improve outcome:

• Agonist treatment with methadone, a long-acting opioid, can reduce heroin use, crime, and the risk of illnesses such as AIDS and viral hepatitis that are associated with IV drug use.
• Buprenorphine, a partial opioid receptor agonist with similar benefits, may soon be approved for the treatment of opiate dependence in outpatient settings.²⁶
• Naltrexone, an opioid receptor antagonist, has long been proposed as a treatment for opiate dependence and has been shown to be effective in alcoholism.²⁷

No effective pharmacologic treatment is available for cocaine dependence, although this is the focus of extensive government-sponsored research.

Principle 11: Educate about addiction and recovery

A wealth of accurate, free information about addiction and recovery is available through Web sites (Box 2) and other sources.

Ideally, outpatients in early recovery should be oriented in how to refuse offers of addictive substances, stress management, relapse prevention, information about the biology of addiction, 12-step fellowship integration, and appropriate use of medications.

Principle 12: Involve families in treatment

Treatment outcomes improve when addicts’ families are involved in the recovery process.^28,29 Some family members enable addictive behavior by purchasing drugs for their relatives or providing money for this purpose, while other families are knowledgeable about treatment and can be a vital force supporting the recovery process

Treatment can help modify unhealthy behavior patterns that some families develop to compensate for a substance abuser’s actions. Because substance use disorders often run in families, try to assess not only the identified patient but also others in the patient’s life.

Related resources

• Center for Substance Abuse Treatment (http://www.health.org/)
• Miller WR. Enhancing motivation for change in substance abuse treatment. CSAT treatment improvement protocol #35. U.S. Department of Health and Human Services, 1999.
• Rawson R. Treatment for stimulant use disorders. CSAT treatment improvement protocol #33. U.S. Department of Health and Human Services, 1999.
• Mercer DE, Woody GE. An individual drug counseling approach to treat cocaine addiction: The Collaborative Cocaine Treatment Study model. NIDA manual #3. Therapy manuals for drug addiction. U.S. Department of Health and Human Services, 1999.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article.

Outpatient treatment of substance abuse is changing as research and experience teach us more about the nature of addictive illness and the principles of recovery. The recommended approach now emphasizes ease of access, chronic rather than acute treatment, and collaboration rather than confrontation.

As psychiatrists, we should be familiar with these changes, so that we can offer our addicted patients effective treatment and referrals. In particular, those of us who lead multidisciplinary teams in mental health clinics and outpatient programs need strategies that will help us make sound clinical decisions on detoxification, medical or psychiatric stabilization, and rehabilitation goals.

A new protocol that addresses these needs is being developed by a consensus panel of the Center for Substance Abuse and Treatment (Box 1).^1,2 Two of us (RFF, RR) are members of that panel, and we all are recognized experts in the outpatient treatment of addicted individuals, with combined experience of more than 70 years. Based on available evidence and expert opinion, we offer you 12 principles of outpatient substance dependence treatment that can help you achieve the most favorable results (Table 1).

Box 1

Principle 1: Open the doors wider

Outpatient clinics were once considered inappropriate for addicted individuals with significant psychosocial problems (such as homelessness) or co-occurring psychiatric disorders. Successful outpatient treatment was thought possible only for high-functioning, employed addicts who were free of significant psychiatric comorbidity.

Today, it is accepted that outpatients with a wide range of biopsychosocial problems can be effectively treated IF they receive case management and housing support and their co-occurring medical and psychiatric conditions are stabilized.

Efforts to ease the addicted patient into treatment should begin the moment a potential patient or family member seeks help. The pleasure that substance abusers derive from drug use makes them typically ambivalent about stopping their compulsive behaviors, and delays or obstacles to admission lead to “no shows” and drop-outs.³ Admissions increase when patients are given appointments the day they call for help.

From the initial outpatient encounter, the patient should feel like a welcomed participant who is responsible for his or her recovery. Access to outpatient programs increases when:

• child-care assistance is provided as needed;
• hours of operation are designed for the patient’s (rather than the staff’s) convenience;
• transportation assistance is provided, particularly for adolescents;
• the treatment plan is flexible and individualized to meet each patient’s specific needs.

Principle 2: Do a comprehensive initial evaluation

The open-door approach is most successful when the psychiatrist performs a comprehensive initial psychiatric and medical evaluation and works closely with a specialized treatment team. The initial medical and psychiatric evaluation is beyond the scope of this article and has been previously reviewed.⁴ Determining the need for medical detoxification is a priority during this phase of treatment.

Drug use patterns The treating physician should maintain a high index of suspicion for conditions associated with drug use. Cocaine causes seizures and cardiac arrhythmias, as well as vasoconstriction that leads to tissue necrosis (i.e., myocardial infarction, stroke, spontaneous abortion, and renal failure). Alcohol abuse affects brain, liver, cardiac, and endocrine tissue. Heroin produces acute overdose through respiratory depression, and its IV route of administration increases the risk of AIDS, viral hepatitis, pneumonia, sepsis, and endocarditis.

Function Structured interviews such as the Addiction Severity Index (ASI)⁵ can be used to assess functional impairment. Because addicted patients may be reluctant to disclose sensitive personal information, it is important to collect collateral information from family and friends, laboratory tests, and medical records.

Psychiatric concerns Many psychiatric syndromes are caused by substance abuse. Cocaine intoxication is often associated with psychosis (paranoia, auditory and tactile hallucinations), panic anxiety, and aggressiveness, whereas cocaine withdrawal produces depressed mood. Depression is also highly associated with chronic alcohol and opiate dependence. Withdrawal from opioids, alcohol, and sedatives produces anxiety.

Patients with bipolar disorder, major depression, panic anxiety, and schizophrenia who present with co-occurring addiction require coordinated and simultaneous stabilization of their addictive and psychiatric disorders.

Table 1

12 PRINCIPLES OF EFFECTIVE OUTPATIENT ADDICTION TREATMENT

Principle 3: Build on existing motivation

That an addicted patient must “hit bottom” before successful treatment may begin is a common misconception. In truth, studies find similar outcomes in individuals who enter treatment voluntarily and those who are externally pressured or legally coerced.⁶ Regardless of patients’ motivation when they enter treatment, they are likely to alternate over time between being more and less motivated. For this reason, it is necessary to remind them why they sought treatment and to use existing external pressures.

For example, with the patient’s consent it would be valuable to maintain contact with a parole officer who mandated a patient’s substance-abuse treatment. Likewise, patients entering treatment under threat of divorce should be asked to consent to family contact and should receive family therapy. Families often provide useful clinical information and can exert powerful influence when the patient’s motivation wanes. A patient’s refusal to allow contact with family (or other important sources of collateral information) often represents resistance that should be explored clinically and addressed.

With open dialogue, resistance to treatment can be reduced with education, peer groups, and family therapy. Motivational enhancement and interviewing work described by Miller, Procaska, and DiClemente^7,8 is designed to reduce treatment resistance in a respectful and clinically effective manner while avoiding confrontation that might provoke dropout and relapse.

Principle 4: Forge a therapeutic alliance

A therapeutic alliance produces positive outcomes in substance-dependent outpatients.^9-11 A recent National Institute on Drug Abuse (NIDA) therapy manual notes that a therapeutic alliance exists when the patient perceives that:

• the clinician accepts and respects him or her;
• the patient’s problems can be overcome by working together with the clinician;
• the clinician understands what the patient is hoping to get out of treatment.¹²

Clinicians can help forge this therapeutic alliance by being active listeners, by being empathic and nonjudgmental, and by approaching treatment as an active collaboration.¹²

Principle 5: Make retention a priority

It is simple but true: you cannot treat a patient who has dropped out.

Treatment retention is associated with better outcomes^13,14 and is a key indicator of the performance of an outpatient treatment program. High drop-out rates are demoralizing to patients who remain in treatment and to the clinicians who must document so-called “3-day treatments.” Because admission and initial evaluation of patients is labor-intensive, premature attrition is costly and time-consuming. Strategies to increase retention are listed in Table 2.

Table 2

STRATEGIES TO RETAIN PATIENTS IN TREATMENT

Clinicians can improve retention by tolerating different rates of change and levels of motivation. Individuals adopt new behaviors at different rates. You might become frustrated when patients do not immediately “buy” a particular version of recovery. Patients, however, often drop out when they feel they are being “force-fed” recommendations for sacrifice and major lifestyle changes that make no sense to them (at least not at the moment).

Principle 6: Provide ongoing care

Addiction is a complex biopsychosocial problem that requires long-term treatment. Even after extended abstinence, substance abusers experience craving and are vulnerable to relapse.

Addicts often enter outpatient treatment with psychosocial, medical, and psychiatric problems. Transformation from active addiction to full functioning in society requires sustained and conscientious effort by the patient, support system, and treatment team. Like asthma, diabetes, and other chronic diseases, addiction requires ongoing care.¹⁵

Unlike other chronic conditions, however, addiction is pleasure-reinforced, and addicted individuals are particularly at risk for relapse. Ongoing care may interrupt a relapse or at least interrupt it sooner than if no ongoing treatment were provided.

Substance dependence treatment for less than 90 days is of little or no use, and treatment lasting significantly longer often is indicated, according to the NIDA.¹⁶ When patients complete an intensive treatment phase, they should be evaluated for readiness to transfer to less-intensive care, with gradual transition from several therapeutic contacts per week, to weekly contact, to semimonthly contact, and so on. The concept of “graduation” should clearly convey not an ending but a “commencement” or beginning, as it does in college.

Unfortunately, the long-term approach to substance dependence is undermined by managed care organizations’ insistence on brief treatments. Also, regulations that view addiction as an acute episode may require that patient charts be closed at the end of intensive treatment. Such failures to appreciate the chronic nature of addiction undermine access to treatment and service delivery and contribute to recidivism and medical, social, criminal, and economic consequences associated with active addiction.

Principle 7: Match services with treatment needs

Outcomes improve when treatment services meet individual needs.¹⁷ Medical, psychiatric, psychosocial, legal, and housing problems can distract patients from the work of therapy. It is important to match each patient’s problems and needs with appropriate treatment settings, interventions, and services, according to the NIDA’s Principles of Drug Addiction Treatment.¹⁶ Creating flexible, responsive programs means more work for the treatment team, but it enhances the quality of care.

Treating concomitant psychiatric illness often requires innovations in outpatient treatment programs. For example, psychiatrists must avoid undermining treatment by inappropriately prescribing addictive agents such as benzodiazepines. At the same time, drug counselors may benefit from education about the potential benefits of medications in treating co-occuring disorders and craving. Coordinated delivery of psychiatric and rehabilitative treatment requires open communication in regularly scheduled multidisciplinary team meetings.

Principle 8: Monitor abstinence

Routine urine drug screens, Breathalyzer tests—administered at least weekly— and/or other laboratory tests to confirm self-reported abstinence can improve treatment outcomes. Regular drug and alcohol monitoring provides an objective indicator of progress, serves as a deterrent, and can help motivate the patient to withstand drug urges.

Individuals attempting abstinence from one substance have better outcomes if they abstain from all addictive substances¹⁸ (although tobacco use is controversial and requires further research). Even so, patients often continue to use addictive substances during treatment. Patients struggling with abstinence should not be discharged from treatment programs for manifesting the symptoms for which they are seeking treatment.

Substance-dependent individuals progress at different rates during treatment, and creative strategies to enhance motivation and retention can ultimately produce positive results. Outpatient clinics should consider different treatment tracks for patients at different stages of readiness for recovery.

Box 2

Principle 9: Use 12-step and other community supports

Patients who participate in 12-step programs and treatments have better outcomes than those who do not.^19-21 Still, patients in early recovery may find it difficult to join community-based support groups, such as Alcoholics Anonymous (AA). Patients are often ambivalent about—or strongly opposed to—joining AA because of embarrassment, negative experiences, or inadequate preparation for joining a 12-step fellowship. Substance abusers who are ambivalent about recovery often dispute 12-step directives on total abstinence, sweeping lifestyle changes, and the need to “give up control” over treatment recommendations. Common issues in early recovery include:

• how to select a 12-step home group and a sponsor;
• how to overcome uneasiness associated with being in a 12-step group;
• how to address any discomfort the patient may feel with the religious nature of 12-step meetings.²²

Patients’ resistance to 12-step treatment should be explored and addressed. Sometimes all they need is encouragement and help in finding a sponsor. Those with more difficult concerns may need a different approach. For example, social phobia is common in alcoholics and can be exacerbated by 12-step meetings; symptoms often respond to beta-adrenergic blockade. Patients with schizophrenia and those with paranoid features often do poorly in 12-step treatment if their paranoid symptoms cannot be successfully managed.

Principle 10: Manage medications

To avoid drug interactions, all prescribers involved with the patient’s care should coordinate their medication management efforts. Many substance abusers suffer from co-occurring psychiatric conditions²³ for which psychiatric medications are standard treatment.^24,25 In addition, medical detoxification is often necessary for heroin, alcohol, and sedative/hypnotic-dependent individuals. These treatments, which are beyond the scope of this article, are best integrated with drug rehabilitation.

Various medications for addiction have been reported to improve outcome:

• Agonist treatment with methadone, a long-acting opioid, can reduce heroin use, crime, and the risk of illnesses such as AIDS and viral hepatitis that are associated with IV drug use.
• Buprenorphine, a partial opioid receptor agonist with similar benefits, may soon be approved for the treatment of opiate dependence in outpatient settings.²⁶
• Naltrexone, an opioid receptor antagonist, has long been proposed as a treatment for opiate dependence and has been shown to be effective in alcoholism.²⁷

No effective pharmacologic treatment is available for cocaine dependence, although this is the focus of extensive government-sponsored research.

Principle 11: Educate about addiction and recovery

A wealth of accurate, free information about addiction and recovery is available through Web sites (Box 2) and other sources.

Ideally, outpatients in early recovery should be oriented in how to refuse offers of addictive substances, stress management, relapse prevention, information about the biology of addiction, 12-step fellowship integration, and appropriate use of medications.

Principle 12: Involve families in treatment

Treatment outcomes improve when addicts’ families are involved in the recovery process.^28,29 Some family members enable addictive behavior by purchasing drugs for their relatives or providing money for this purpose, while other families are knowledgeable about treatment and can be a vital force supporting the recovery process

Treatment can help modify unhealthy behavior patterns that some families develop to compensate for a substance abuser’s actions. Because substance use disorders often run in families, try to assess not only the identified patient but also others in the patient’s life.

Related resources

• Center for Substance Abuse Treatment (http://www.health.org/)
• Miller WR. Enhancing motivation for change in substance abuse treatment. CSAT treatment improvement protocol #35. U.S. Department of Health and Human Services, 1999.
• Rawson R. Treatment for stimulant use disorders. CSAT treatment improvement protocol #33. U.S. Department of Health and Human Services, 1999.
• Mercer DE, Woody GE. An individual drug counseling approach to treat cocaine addiction: The Collaborative Cocaine Treatment Study model. NIDA manual #3. Therapy manuals for drug addiction. U.S. Department of Health and Human Services, 1999.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article.

Outpatient treatment of substance abuse is changing as research and experience teach us more about the nature of addictive illness and the principles of recovery. The recommended approach now emphasizes ease of access, chronic rather than acute treatment, and collaboration rather than confrontation.

As psychiatrists, we should be familiar with these changes, so that we can offer our addicted patients effective treatment and referrals. In particular, those of us who lead multidisciplinary teams in mental health clinics and outpatient programs need strategies that will help us make sound clinical decisions on detoxification, medical or psychiatric stabilization, and rehabilitation goals.

A new protocol that addresses these needs is being developed by a consensus panel of the Center for Substance Abuse and Treatment (Box 1).^1,2 Two of us (RFF, RR) are members of that panel, and we all are recognized experts in the outpatient treatment of addicted individuals, with combined experience of more than 70 years. Based on available evidence and expert opinion, we offer you 12 principles of outpatient substance dependence treatment that can help you achieve the most favorable results (Table 1).

Box 1

Principle 1: Open the doors wider

Outpatient clinics were once considered inappropriate for addicted individuals with significant psychosocial problems (such as homelessness) or co-occurring psychiatric disorders. Successful outpatient treatment was thought possible only for high-functioning, employed addicts who were free of significant psychiatric comorbidity.

Today, it is accepted that outpatients with a wide range of biopsychosocial problems can be effectively treated IF they receive case management and housing support and their co-occurring medical and psychiatric conditions are stabilized.

Efforts to ease the addicted patient into treatment should begin the moment a potential patient or family member seeks help. The pleasure that substance abusers derive from drug use makes them typically ambivalent about stopping their compulsive behaviors, and delays or obstacles to admission lead to “no shows” and drop-outs.³ Admissions increase when patients are given appointments the day they call for help.

From the initial outpatient encounter, the patient should feel like a welcomed participant who is responsible for his or her recovery. Access to outpatient programs increases when:

• child-care assistance is provided as needed;
• hours of operation are designed for the patient’s (rather than the staff’s) convenience;
• transportation assistance is provided, particularly for adolescents;
• the treatment plan is flexible and individualized to meet each patient’s specific needs.

Principle 2: Do a comprehensive initial evaluation

The open-door approach is most successful when the psychiatrist performs a comprehensive initial psychiatric and medical evaluation and works closely with a specialized treatment team. The initial medical and psychiatric evaluation is beyond the scope of this article and has been previously reviewed.⁴ Determining the need for medical detoxification is a priority during this phase of treatment.

Drug use patterns The treating physician should maintain a high index of suspicion for conditions associated with drug use. Cocaine causes seizures and cardiac arrhythmias, as well as vasoconstriction that leads to tissue necrosis (i.e., myocardial infarction, stroke, spontaneous abortion, and renal failure). Alcohol abuse affects brain, liver, cardiac, and endocrine tissue. Heroin produces acute overdose through respiratory depression, and its IV route of administration increases the risk of AIDS, viral hepatitis, pneumonia, sepsis, and endocarditis.

Function Structured interviews such as the Addiction Severity Index (ASI)⁵ can be used to assess functional impairment. Because addicted patients may be reluctant to disclose sensitive personal information, it is important to collect collateral information from family and friends, laboratory tests, and medical records.

Psychiatric concerns Many psychiatric syndromes are caused by substance abuse. Cocaine intoxication is often associated with psychosis (paranoia, auditory and tactile hallucinations), panic anxiety, and aggressiveness, whereas cocaine withdrawal produces depressed mood. Depression is also highly associated with chronic alcohol and opiate dependence. Withdrawal from opioids, alcohol, and sedatives produces anxiety.

Patients with bipolar disorder, major depression, panic anxiety, and schizophrenia who present with co-occurring addiction require coordinated and simultaneous stabilization of their addictive and psychiatric disorders.

Table 1

12 PRINCIPLES OF EFFECTIVE OUTPATIENT ADDICTION TREATMENT

Principle 3: Build on existing motivation

That an addicted patient must “hit bottom” before successful treatment may begin is a common misconception. In truth, studies find similar outcomes in individuals who enter treatment voluntarily and those who are externally pressured or legally coerced.⁶ Regardless of patients’ motivation when they enter treatment, they are likely to alternate over time between being more and less motivated. For this reason, it is necessary to remind them why they sought treatment and to use existing external pressures.

For example, with the patient’s consent it would be valuable to maintain contact with a parole officer who mandated a patient’s substance-abuse treatment. Likewise, patients entering treatment under threat of divorce should be asked to consent to family contact and should receive family therapy. Families often provide useful clinical information and can exert powerful influence when the patient’s motivation wanes. A patient’s refusal to allow contact with family (or other important sources of collateral information) often represents resistance that should be explored clinically and addressed.

With open dialogue, resistance to treatment can be reduced with education, peer groups, and family therapy. Motivational enhancement and interviewing work described by Miller, Procaska, and DiClemente^7,8 is designed to reduce treatment resistance in a respectful and clinically effective manner while avoiding confrontation that might provoke dropout and relapse.

Principle 4: Forge a therapeutic alliance

A therapeutic alliance produces positive outcomes in substance-dependent outpatients.^9-11 A recent National Institute on Drug Abuse (NIDA) therapy manual notes that a therapeutic alliance exists when the patient perceives that:

• the clinician accepts and respects him or her;
• the patient’s problems can be overcome by working together with the clinician;
• the clinician understands what the patient is hoping to get out of treatment.¹²

Clinicians can help forge this therapeutic alliance by being active listeners, by being empathic and nonjudgmental, and by approaching treatment as an active collaboration.¹²

Principle 5: Make retention a priority

It is simple but true: you cannot treat a patient who has dropped out.

Treatment retention is associated with better outcomes^13,14 and is a key indicator of the performance of an outpatient treatment program. High drop-out rates are demoralizing to patients who remain in treatment and to the clinicians who must document so-called “3-day treatments.” Because admission and initial evaluation of patients is labor-intensive, premature attrition is costly and time-consuming. Strategies to increase retention are listed in Table 2.

Table 2

STRATEGIES TO RETAIN PATIENTS IN TREATMENT

Clinicians can improve retention by tolerating different rates of change and levels of motivation. Individuals adopt new behaviors at different rates. You might become frustrated when patients do not immediately “buy” a particular version of recovery. Patients, however, often drop out when they feel they are being “force-fed” recommendations for sacrifice and major lifestyle changes that make no sense to them (at least not at the moment).

Principle 6: Provide ongoing care

Addiction is a complex biopsychosocial problem that requires long-term treatment. Even after extended abstinence, substance abusers experience craving and are vulnerable to relapse.

Addicts often enter outpatient treatment with psychosocial, medical, and psychiatric problems. Transformation from active addiction to full functioning in society requires sustained and conscientious effort by the patient, support system, and treatment team. Like asthma, diabetes, and other chronic diseases, addiction requires ongoing care.¹⁵

Unlike other chronic conditions, however, addiction is pleasure-reinforced, and addicted individuals are particularly at risk for relapse. Ongoing care may interrupt a relapse or at least interrupt it sooner than if no ongoing treatment were provided.

Substance dependence treatment for less than 90 days is of little or no use, and treatment lasting significantly longer often is indicated, according to the NIDA.¹⁶ When patients complete an intensive treatment phase, they should be evaluated for readiness to transfer to less-intensive care, with gradual transition from several therapeutic contacts per week, to weekly contact, to semimonthly contact, and so on. The concept of “graduation” should clearly convey not an ending but a “commencement” or beginning, as it does in college.

Unfortunately, the long-term approach to substance dependence is undermined by managed care organizations’ insistence on brief treatments. Also, regulations that view addiction as an acute episode may require that patient charts be closed at the end of intensive treatment. Such failures to appreciate the chronic nature of addiction undermine access to treatment and service delivery and contribute to recidivism and medical, social, criminal, and economic consequences associated with active addiction.

Principle 7: Match services with treatment needs

Outcomes improve when treatment services meet individual needs.¹⁷ Medical, psychiatric, psychosocial, legal, and housing problems can distract patients from the work of therapy. It is important to match each patient’s problems and needs with appropriate treatment settings, interventions, and services, according to the NIDA’s Principles of Drug Addiction Treatment.¹⁶ Creating flexible, responsive programs means more work for the treatment team, but it enhances the quality of care.

Treating concomitant psychiatric illness often requires innovations in outpatient treatment programs. For example, psychiatrists must avoid undermining treatment by inappropriately prescribing addictive agents such as benzodiazepines. At the same time, drug counselors may benefit from education about the potential benefits of medications in treating co-occuring disorders and craving. Coordinated delivery of psychiatric and rehabilitative treatment requires open communication in regularly scheduled multidisciplinary team meetings.

Principle 8: Monitor abstinence

Routine urine drug screens, Breathalyzer tests—administered at least weekly— and/or other laboratory tests to confirm self-reported abstinence can improve treatment outcomes. Regular drug and alcohol monitoring provides an objective indicator of progress, serves as a deterrent, and can help motivate the patient to withstand drug urges.

Individuals attempting abstinence from one substance have better outcomes if they abstain from all addictive substances¹⁸ (although tobacco use is controversial and requires further research). Even so, patients often continue to use addictive substances during treatment. Patients struggling with abstinence should not be discharged from treatment programs for manifesting the symptoms for which they are seeking treatment.

Substance-dependent individuals progress at different rates during treatment, and creative strategies to enhance motivation and retention can ultimately produce positive results. Outpatient clinics should consider different treatment tracks for patients at different stages of readiness for recovery.

Box 2

Principle 9: Use 12-step and other community supports

Patients who participate in 12-step programs and treatments have better outcomes than those who do not.^19-21 Still, patients in early recovery may find it difficult to join community-based support groups, such as Alcoholics Anonymous (AA). Patients are often ambivalent about—or strongly opposed to—joining AA because of embarrassment, negative experiences, or inadequate preparation for joining a 12-step fellowship. Substance abusers who are ambivalent about recovery often dispute 12-step directives on total abstinence, sweeping lifestyle changes, and the need to “give up control” over treatment recommendations. Common issues in early recovery include:

• how to select a 12-step home group and a sponsor;
• how to overcome uneasiness associated with being in a 12-step group;
• how to address any discomfort the patient may feel with the religious nature of 12-step meetings.²²

Patients’ resistance to 12-step treatment should be explored and addressed. Sometimes all they need is encouragement and help in finding a sponsor. Those with more difficult concerns may need a different approach. For example, social phobia is common in alcoholics and can be exacerbated by 12-step meetings; symptoms often respond to beta-adrenergic blockade. Patients with schizophrenia and those with paranoid features often do poorly in 12-step treatment if their paranoid symptoms cannot be successfully managed.

Principle 10: Manage medications

To avoid drug interactions, all prescribers involved with the patient’s care should coordinate their medication management efforts. Many substance abusers suffer from co-occurring psychiatric conditions²³ for which psychiatric medications are standard treatment.^24,25 In addition, medical detoxification is often necessary for heroin, alcohol, and sedative/hypnotic-dependent individuals. These treatments, which are beyond the scope of this article, are best integrated with drug rehabilitation.

Various medications for addiction have been reported to improve outcome:

• Agonist treatment with methadone, a long-acting opioid, can reduce heroin use, crime, and the risk of illnesses such as AIDS and viral hepatitis that are associated with IV drug use.
• Buprenorphine, a partial opioid receptor agonist with similar benefits, may soon be approved for the treatment of opiate dependence in outpatient settings.²⁶
• Naltrexone, an opioid receptor antagonist, has long been proposed as a treatment for opiate dependence and has been shown to be effective in alcoholism.²⁷

No effective pharmacologic treatment is available for cocaine dependence, although this is the focus of extensive government-sponsored research.

Principle 11: Educate about addiction and recovery

A wealth of accurate, free information about addiction and recovery is available through Web sites (Box 2) and other sources.

Ideally, outpatients in early recovery should be oriented in how to refuse offers of addictive substances, stress management, relapse prevention, information about the biology of addiction, 12-step fellowship integration, and appropriate use of medications.

Principle 12: Involve families in treatment

Treatment outcomes improve when addicts’ families are involved in the recovery process.^28,29 Some family members enable addictive behavior by purchasing drugs for their relatives or providing money for this purpose, while other families are knowledgeable about treatment and can be a vital force supporting the recovery process

Treatment can help modify unhealthy behavior patterns that some families develop to compensate for a substance abuser’s actions. Because substance use disorders often run in families, try to assess not only the identified patient but also others in the patient’s life.

Related resources

• Center for Substance Abuse Treatment (http://www.health.org/)
• Miller WR. Enhancing motivation for change in substance abuse treatment. CSAT treatment improvement protocol #35. U.S. Department of Health and Human Services, 1999.
• Rawson R. Treatment for stimulant use disorders. CSAT treatment improvement protocol #33. U.S. Department of Health and Human Services, 1999.
• Mercer DE, Woody GE. An individual drug counseling approach to treat cocaine addiction: The Collaborative Cocaine Treatment Study model. NIDA manual #3. Therapy manuals for drug addiction. U.S. Department of Health and Human Services, 1999.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article.