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Comparison of the effectiveness of a 12 step substance use recovery
program on quality of life.
Authors:
Mokhtari, Mohammad Reza; 1Alavi, Mousa; 2Pahlavanzadeh, Saeid; 2Weimand, Bente M.; 3,4,5Visentin, Denis; 6Cleary, Michelle7
Affiliation:
1Student Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
2
Mental Health Nursing Department, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
3Department of Nursing and Health Promotion, OsloMet – Oslo Metropolitan University, Oslo, Norway
4Department of Evidence and Social Innovation, School of Nursing and Midwifery, Queens University, Belfast, Ireland
5
Department of Research and Development Mental Health, Akershus University Hospital, Lørenskog, Norway
6School of Health Sciences, University of Tasmania, Sydney New South Wales,, Australia
7School of Nursing, University of Tasmania, Sydney New South Wales,, Australia
Source:
Nursing & Health Sciences (NURS HEALTH SCI), Jun2020; 22(2): 390-397. (8p)
Publication Type:
Journal Article – clinical trial, research, tables/charts
Language:
English
Major Subjects:
Substance Use Disorders
Recovery
Quality of Life
Health Education
Substance Use Rehabilitation Programs — Evaluation
Substance Abusers — Education — Iran
Outcomes of Education — Evaluation
Minor Subjects:
Human; Comparative Studies; Quasi-Experimental Studies; Pretest-Posttest Design; Male; Female; Adult; Clinical Trials; Funding Source; Program
Evaluation; Iran; Substance Dependence — Therapy; Health Facilities; Mental Health; Health Status; Affective Disorders — Prevention and Control; Time
Factors; Questionnaires; Summated Rating Scaling; T-Tests; Chi Square Test; Analysis of Covariance; Data Analysis Software; Descriptive Statistics
Abstract:
Substance‐related disorders can adversely impact quality of life. This study assessed a 12 step program on health‐related quality of life for Iranian
individuals seeking to recover from substance use. The study used a quasi‐experimental, two group, three stage, pre‐ and post‐test design and
collected data at baseline, and at 1 and 3 months’ post‐intervention. The treatment group comprised 35 participants in a 12 step program with a non‐
equivalent comparison group of individuals admitted to addiction treatment centers. Physical and mental health quality‐of‐life domains were assessed
using the Short Form 36 Health Survey Questionnaire. The treatment group improved in all aspects of health‐related quality of life. The treatment group
improved compared to the comparison group for two of eight quality of life dimensions – physical functioning and role limitations due to emotional
problems – at 1 month post‐intervention. There were additional improvements at 3 months’ follow up in six of eight quality‐of‐life subscales compared to
the comparison group. The benefits to quality of life related to mental health recovery extended beyond the treatment program, indicating that the
program principles were effectively implemented in daily life.
Journal Subset:
Asia; Nursing; Peer Reviewed
Instrumentation:
Short Form 36 Health Survey Questionnaire.
ISSN:
1441-0745
MEDLINE Info:
NLM UID: 100891857
Grant Information:
Supported by Isfahan University of Medical Sciences, Iran, Grant/AwardNumber: 396623.
Entry Date:
20200627
Revision Date:
20210601
DOI:
10.1111/nhs.12668
Accession Number: 144222315
Publisher Logo:
Comparison of the effectiveness of a 12 step substance use recovery program
on quality of life
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Substance‐related disorders can adversely impact quality of life. This study assessed a 12 step program on health‐related quality of life for Iranian individuals
seeking to recover from substance use. The study used a quasi‐experimental, two group, three stage, pre‐ and post‐test design and collected data at baseline,
and at 1 and 3 months’ post‐intervention. The treatment group comprised 35 participants in a 12 step program with a non‐equivalent comparison group of
individuals admitted to addiction treatment centers. Physical and mental health quality‐of‐life domains were assessed using the Short Form 36 Health Survey
Questionnaire. The treatment group improved in all aspects of health‐related quality of life. The treatment group improved compared to the comparison group for
two of eight quality of life dimensions – physical functioning and role limitations due to emotional problems – at 1 month post‐intervention. There were additional
improvements at 3 months’ follow up in six of eight quality‐of‐life subscales compared to the comparison group. The benefits to quality of life related to mental
health recovery extended beyond the treatment program, indicating that the program principles were effectively implemented in daily life.
Keywords: health‐related quality of life; Iran; mental health recovery; substance‐related disorder
INTRODUCTION
Substance misuse is a complex mental health problem associated with psychiatric and physical comorbidities (Hunt, Large, Cleary, Lai, & Saunders, [13]; Hunt,
Malhi, Cleary, Lai, & Sitharthan, [14]; Karow et al., [18]). Addiction involves a loss of control and behaviors that are both compulsive and habitual (Mendola &
Gibson, [26]). The persistent use of alcohol or illicit drugs often has adverse consequences and contributes to unemployment, homelessness, relationship
breakdowns, aggression, high rates of hospitalization, and incarceration (Hunt et al., [13]; Vanderplasschen et al., [38]). Substance use disorders have high
prevalence rates (Donovan, Ingalsbe, Benbow, & Daley, [ 6]), contributing to the high and growing global burden related to years of life lost and disability‐adjusted
life years, which provide challenges for health systems, particularly in developing regions (Gowing et al., [11]; Whiteford et al., [41]).
There are a range of services for psychosocial interventions for people with substance use disorders, including detoxification programs, outpatient treatment,
methadone maintenance therapy, short and long‐term residential programs, and harm‐minimization programs (Vanderplasschen et al., [38]). A variety of
psychosocial treatment approaches can be used, including counseling, cognitive behavior therapy, psychotherapy, medication, and motivational interviewing
(Horsfall, Cleary, Hunt, & Walter, [12]; Hunt, Siegfried, Morley, Sitharthan, & Cleary, [15]; Noosorn, Phetphum, & Yau, [32]). Treatments can be delivered in
combination or sequentially, and across settings (Mendola & Gibson, [26]).
The 12 step program of recovery is the best known approach for a range of addictions, and is widely available in many countries and online (Mendola & Gibson,
[26]). The program was developed and achieved widespread use through the Alcoholics Anonymous program, which was later extended to other addictions
(Galanter & Kaskutas, [10]). The 12 step philosophy emphasizes the importance of accepting addiction as a disease that can be treated but not cured. The
program promotes individual responsibility and personal growth, assisting others living with addiction by sharing recovery stories and sponsoring new attendees.
The 12 step program aids coping with recovery, motivation, abstinence with improved mental health and well‐being, and decreases impulsivity and craving (Kelly,
Humphreys, & Ferri, [19]). Involvement in a 12 step group provides support through a social network, and a set of 12 guiding principles for recovery (Donovan et
al., [ 6]). This approach is based on the goals of returning to spiritual health, promoting self‐esteem, and enhancing the desire for continuity of recovery from
substance use (White et al., [40]). Meetings are typically held by the peer group with minimal collaboration and supervision by health team members (White et al.,
[40]), are easily accessed, and have no healthcare costs, unlike other clinical recovery programs (Donovan et al., [ 6]). The program can be used independently
or in combination with other treatment options (Tracy & Wallace, [37]).
A number of substance recovery and support programs rely on the benefits of peer support. Peer support involves non‐professional help from those with similar
conditions (Tracy & Wallace, [37]). Peer support based on mutual aid modalities are provided in programs, such as 12 step groups (Bassuk, Hanson, Greene,
Richard, & Laudet, [ 3]). Social support has been found to be associated with greater readiness to change and decreased substance use (Lookatch, Wimberly, &
McKay, [24]). The peer support relationship is fundamental to achieving and maintaining abstinence in 12 step programs, which has demonstrated positive long‐
term outcomes (Laudet, Savage, & Mahmood, [23]; Moos & Moos, [30], [31]).
Studies have examined and supported the effectiveness of the 12 step program on recovery and improved psychosocial outcomes, including health‐related
quality of life (QoL) (Donovan et al., [ 6]). QoL is a broad concept that involves a perception of one’s life in the context of local culture and value systems related
to aspirations, expectations, and community standards (Feelemyer, Jarlais, Arasteh, Phillips, & Hagan, [ 7]). The effectiveness of interventions for the QoL of
individuals with substance use has been assessed across a number of programs (Feelemyer et al., [ 7]; Karow et al., [18]). Social networks have been
demonstrated to achieve treatment goals and abstinence, irrespective of the origin of this support, and are identified as vital to sustained recovery (Lookatch et
al., [24]).
While many studies have evaluated the effectiveness of the 12 step program across a range of outcome measures, the evidence for its superiority to other
treatments is limited (Ferri, Amato, & Davoli, [ 9]). Most studies that have compared the 12 step program to other treatments have found similar retention rates
and treatment outcomes in both study arms (Karlsson & Bergmark, [17]). A Cochrane review of the 12 step program found only eight trials, indicating the
necessity of further comparison trials (Ferri et al., [ 9]). An assessment of treatment efficacy requires well‐designed randomized, controlled trials with appropriate
control groups and standardized assessment of treatment outcomes and adherence (Karlsson & Bergmark, [17]). The treatment goals of programs might vary,
making it difficult to have consistent outcome measures for comparison studies in addiction recovery. In particular, the difference between programs which focus
on harm reduction rather than abstinence might be difficult to compare to the 12 step approach (Mendola & Gibson, [26]).
Iran and many Middle Eastern countries prohibit and stigmatize substance use, such as opioids, amphetamines, and alcohol (Aghakhani, Lopez, & Cleary, [ 1];
Fereidouni et al., [ 8]); however, the Middle East is the world’s largest narcotics producer, increasing the availability of illicit drugs. As a result, substance use in
Iran has been identified as a major health issue (Shahbazi, Mirtorabi, Ghadirzadeh, Hashemi‐Nazari, & Barzegar, [35]), which contributes a major socioeconomic
cost to the individuals affected and their families (Damari, Ahmadi Pishkuhi, Masoudiasl, & Bostanmanesh, [ 5]). Health issues and mortality associated with
substance use contributes to the burden of disease in Iran, with men experiencing higher rates of both death and disability (Moazen et al., [27]). The
effectiveness of the 12 step program on QoL for substance abuse in the Iranian context has not been fully explored.
The aim of this study was to compare the effect of the 12 step program on the QoL of individuals with substance use to treatment center admission.
METHODS
Sample and setting
This study was a pretest, post‐test non‐equivalent quasi‐experimental design conducted from September 2018 to March 2019. The intervention and comparison
groups were selected through a convenience sampling method.
The intervention group was drawn from volunteer members of an addiction recovery program supported by a non‐government organization, while comparison
participants were drawn from addiction treatment centers affiliated with Isfahan University of Medical Sciences (IUMS), Iran. Eight of the 164 addiction treatment
centers were selected for inclusion based on their location to cover different regions of Isfahan to ensure a more representative sample.
The sample size was calculated using the results of a previous study (Momeni, Moshtagh, & Pourshahbaz, [28]), in which the post‐test QoL scores in the control
and the intervention groups were 73.43 ± 16.13 and 89.4 ± 16.72, respectively, giving an effect size of.973. Considering a type I error probability of.05 and a
power of.90, the sample size required was determined to be 24 people for each group using G‐power software. To account for attrition, 35 participants were
included in each group. One hundred and forty two people were approached; 74 were volunteers of an addiction recovery program and 68 were clients of
addiction treatment centers. Seventy two people were excluded due to not meeting the inclusion criteria (n = 28) or declining to participate (n = 44) (Figure).
Flow diagram for the study
Participants were included if they had voluntary membership in the addiction recovery program groups or were admitted voluntarily to the treatment centers. The
inclusion criteria were the ability to communicate, read and write in Persian, Iranian, aged 20–40 years, and not simultaneously attending a similar treatment
program. Exclusion criteria were having physical illnesses causing functional impairment, current drug use, and being incarcerated in the previous 3 months.
Participants were excluded from the analysis if they missed two consecutive training sessions.
Data collection and instruments
The data‐collection instrument consisted of two parts: (i) demographic characteristics including age, substance use history (i.e. the time since first drug use,
starting age of substance use), sex, education status, marital status, employment status, housing status, number of siblings, income status, number of treatment
attempts; and (ii) the Short Form 36 Health Survey Questionnaire (SF‐36) (Ware, Snow, Kosinski, & Gandek, [39]).
The SF‐36 is a widely‐used, generic, self‐report measure to assess health‐related QoL in both clinical and healthy populations. It is composed of 36 questions
comprising eight subscales assessing physical and mental health. The physical health domain consists of physical functioning, role limitations due to physical
health problems, bodily pain, and general health perceptions; the mental health domain includes vitality, social functioning, role limitations due to emotional
problems, and general mental health. Response categories are Likert type, ranging from two to six levels. SF‐36 scale scores are transformed linearly to a scale
from 0 to 100, with higher scores indicating better health‐related QoL. The validity and reliability of the Persian version of this questionnaire has already been
supported, with Cronbach’s alpha coefficients ranging from.77 to.90 with the exception of the vitality scale (α =.65) (Montazeri, Goshtasebi, Vahdaninia, &
Gandek, [29]). Permission was granted to use the scale.
Interventions
The treatment intervention consisted of a 12 step program over 12 sessions, with three sessions weekly, each lasting 1.5 hours. The program followed a standard
procedure of delivery of a 12 step program. The sessions were facilitated by a nurse, with each new session introducing and outlining the “step”, with participants
undertaking facilitated peer support discussion around the step. For example, in the first session, the first step was introduced, which involved accepting the
individual’s powerlessness over addiction. Participants were then invited to express their own self‐admission and story according to this principle. Discussion and
affirmation of others was encouraged throughout the process to meet the peer support aspects of the program. Participants in the intervention group did not
participate in any similar training programs during the study. The comparison group received routine interventions provided by treatment centers involving
rehabilitation and mental health counseling services.
Questionnaires were completed by both groups before the intervention, and at 1 and 3 months’ follow up.
Statistical analysis
Independent samples t‐tests and χ2‐tests were used to compare the baseline SF‐36 subscale scores and demographic data and individual characteristics of the
study groups. Data are reported as mean differences from baseline values. Analysis of covariance (ANCOVA) was used to assess the between‐group differences
in the mean SF‐36 scores at 1 and 3 months after the intervention, controlling for pretest scores as a covariate. The data were analyzed using SPSS software
Ethical considerations
Written, informed consent was obtained from all participants. Approval was given by the Vice‐Chancellery for Research of the IUMS (research ID: 396623).
RESULTS
Demographic data and individual characteristics of the two groups are presented in Table. The results showed that the two groups did not differ significantly in
terms of demographic characteristics and substance use history.
Comparison of demographic and individual characteristics between the two groups
Variable
Control group
Mean (SD) or N (%)
Mean (SD) or N (%)
Intervention groupTest statisticP‐value
Age
30.06 (5.36)
30.83 (4.96)
t =.63
.53
Drug usage history (month)
123.26 (47.46)
111.46 (41.79)
t = −1.10
.27
Starting age of substance use20.34 (2.58)
21.29 (3.14)
t = 1.37
.17
No. children
.66 (.14)
.51 (.12)
t = −.79
.43
No. treatment attempts
2.97 (.34)
2.91 (.50)
t =.095
.93
Gender
Male
18 (51.4)
16 (45.7)
χ2 = .63 .81
Female
17 (48.6)
19 (54.3)
Education
Elementary school 10 (28.6)
11 (31.4)
χ2 =.35 .99
Middle school
11 (31.4)
10 (28.6)
High school
6 (17.2)
6 (17.2)
Diploma
3 (8.5)
4 (11.4)
University degree
5(14.3)
4 (11.4)
Income
Exceeds needs
1 (2.9)
1 (2.9)
χ2 = 2.53.47
Normal
15 (42.9)
18 (51.4)
Low
19 (54.3)
16 (45.7)
Marital status
Single
13 (37.1)
15 (42.9)
χ2 = 1.37.71
Married
16 (45.7)
17 (48.5)
Divorced
3 (8.6)
1 (2.9)
Partner
3 (8.6)
2 (5.7)
Employment status
Unemployed
14 (40)
15 (42.9)
χ2 =.06 .97
Working
20 (57.1)
19 (54.3)
Disabled
1 (2.9)
1 (2.9)
Housing status
Own
9 (25.7)
9 (25.7)
χ2 =.88 .93
Rental
12 (34.3)
12 (34.3)
Worker accommodation
4 (11.4)
3 (8.6)
Homeless
8 (22.9)
7 (20.0)
Shelter
2 (5.7)
4 (11.4)
Location
City
7 (20.0)
6 (17.1)
χ2 = 1.12.57
Village
8 (22.9)
12 (34.3)
Town
20 (57.1)
17 (48.6)
1 Abbreviations: SD = standard deviation.
The treatment group improved significantly in all SF‐36 subscale measures at the 1 month follow up compared to baseline (P < .001 for all measures). Highest
improvements were in role limitations due to physical health problems (mean difference, MD = 17.15), role limitations due to emotional problems (MD = 14.28),
bodily pain (MD = 14.00), general health perceptions (MD = 13.57), and physical functioning (MD = 11.72). The treatment group also demonstrated significant
improvements in all SF‐36 subscale measures at the 3 month follow up compared to baseline (P < .001 for all measures), with a doubling of scores from baseline
for four measures. Highest improvements were in general health perceptions (MD = 46.43), role limitations due to physical health problems (MD = 42.15), role
limitations due to emotional problems (MD = 35.24), vitality (MD = 34.95), and bodily pain (MD = 33.28). The control group also had significant improvements in
six of the eight subscale measures at the 1 month follow up and in seven of the eight subscale measures at the 3 month follow up compared to baseline (Table).
Mean and standard deviation (SD) of dimensions of the Short Form 36 Health Survey Questionnaire in both groups at baseline and at 1 and 3 months' follow up,
and analysis of covariance results controlling for baseline
Dimension of quality of life
Intervention group
Within‐group
Control group
test
Mean (SD)
P‐value compared to
Mean (SD)
baseline
Within‐group
Between‐group test
test
P‐value compared to
P‐value
Partial eta squared
(ηp2)
baseline
Physical functioning
Baseline
36.14 (11.7)
—
34.71 (9.47)
—
.58
1 month follow up
47.86 (13.13)
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