Maintenance of abstinence in self-help groups

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Maintenance of abstinence in self-help groups

Bertrand Nalpas, Isabelle Boulze-Launay

To cite this version:

Bertrand Nalpas, Isabelle Boulze-Launay. Maintenance of abstinence in self-help groups. Alcohol and

Alcoholism, Oxford University Press (OUP), 2017, 53 (1), pp.89-94. �hal-03063229�

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doi: 10.1093/alcalc/agx085 Advance Access Publication Date: 26 October 2017 Article

Article

Maintenance of Abstinence in Self-Help Groups

Bertrand Nalpas

1,2,

* and Isabelle Boulze-Launay

2,3

, the Inserm Alcohol

Group

4

1

_{Inserm Scienti}

_{ﬁc Information and Communication Department, Inserm, Paris, France,}

2

_{Department of}

Addictology, CHRU Caremeau, Nîmes, France,

3

_{Epsylon Laboratory, Dynamics of Human Abilities and Health}

Behaviours, Montpellier University III, Montpellier, France, and

4

_{The Inserm Alcohol Group comprises the}

follow-ing members representfollow-ing self-help organisations for people with alcohol problems (in alphabetical order):

Alcooliques Anonymes, Alcool Assistance, Alcool Ecoute Joie et Santé, Amis de la Santé, Amitié La Poste, Croix

Bleue, Santé de la Famille, Vie Libre.

*Corresponding author: Department of Scientiﬁc Information and Communication, Inserm, 101 rue de Tolbiac, 75654 Paris Cedex 13, France. Tel:+33-1-44-23-6109; E-mail: bertrand.nalpas@inserm.fr

Received 15 June 2017; Revised 21 August 2017; Editorial Decision 6 October 2017; Accepted 7 October 2017

Abstract

Aim: To analyse abstinence rates 12 months after alcohol cessation in a sample of French subjects

participating in support group meetings.

Method: The project was co-designed with support group representatives, and co-investigator

roles were delegated to meeting managers. Subjects who had stopped drinking for

<3 months

were included. An independent investigator evaluated alcohol intake and group attendance every

3 months using a questionnaire, and time to

ﬁrst drink was analysed using survival curves.

Results: Overall, 145 participants were included, mean age 47 years. At 1 year, 43% of the 119

who could be evaluated were abstinent. Relapse rates did not differ by gender, withdrawal

meth-od, previous stays in a rehabilitation unit or time of

ﬁrst contact with the self-help association.

However, participants receiving specialist medical and/or psychological support in addition to

attending group meetings had a signi

ﬁcantly lower abstinence rate than those who only attended

group meetings, although their attendance at group meetings was similar.

Conclusion: Self-help associations can participate in rigorous scienti

ﬁc studies. The present results

identi

ﬁed a subgroup of individuals with alcohol problems who attended self-help groups, but not

traditional care pathways. Having additional specialist support was not associated with better

outcome.

INTRODUCTION

There are many sources of help for people with alcohol problems, including (in no particular order): general practitioners, occupa-tional physicians, specialized care centres, psychiatrists, psycholo-gists, social workers and self-help associations. To maintain abstinence, most alcoholics will rely on one, or a combination of these sources over time.

Although the care pathways vary widely, especially at the stage of entry into treatment, analysis of the different processes reveals three main stages in which certain types of support are more import-ant than others.

In theﬁrst stage, before the patient attempts alcohol cessation, the typical sources of support are the patient’s friends and family, their general practitioner, and the self-help organizations the patient approaches for information. The medical component becomes more important in the second stage of detoxiﬁcation, for carrying out an impact assessment and preventing complications associated with abrupt cessation. In the third stage, post-withdrawal, the importance of this medical component decreases in favour of psychological and social support (Ouimette et al., 1998). A study of French patients followed up in the Centre for Care, Support and Prevention in Addiction showed that psychologists and social workers were the

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most active during the patient’s time in care (Nalpas et al., 2006). Self-help organizations for people with alcohol problems constituted the third most important source of support (Mueller et al., 2007).

The progression of alcoholism is characterized by periods of withdrawal and relapse with considerable variation in timing and duration. In the same way that analysing the trajectory via which people enter into a disease state is a research objective with a view to prevention, analysing the way in which they emerge from this state into recovery makes it possible to refine treatment strategies. The difficulty in the study of alcoholism is that while the criterion of effectiveness of care remains the patient’s attitude towards alcohol, its definition is variable: complete abstinence, abstinence until the first period of alcohol intake for 3 consecutive days, the number of days of heavy drinking, the number of days without alcohol and so on (Witkiewitz et al., 2015). In addition, evaluations usually take place 3 months after withdrawal, which is unanimously recognized as insufficient, since relapses still occur after 6 months (Hayashida et al., 1989). Relapse rates at 3 or 6 months may range from 35 to 90% (de Bejczy et al., 2014;Mason et al., 2014;Yoshimura et al., 2014;Rose et al., 2015).

Self-help organizations for people with alcohol problems, whether they are open to everyone or private, and whatever their function or type of organization, tend to share a common philoso-phy: the goal of complete abstinence from any alcohol. This is con-sidered essential to restoring the physical and psychological balance that alcohol destroys. The efﬁcacy criterion here is simple and bin-ary: alcohol or no alcohol.

The impact of participation in self-help meetings on long-term abstinence has been the subject of much research, the results of which are contradictory. Some conclude that such meetings improve outcome (Witbrodt et al., 2012;Pagano et al., 2013), while others conclude differently (Ferri et al., 2006). Most of this work has been carried out in clinical trials with patient cohorts, or studies of inter-vention strategies. However, to our knowledge, there are no studies in France that use community-based approaches to investigate the role of self-help organizations, whether or not they are associated with conventional therapeutic approaches.

In the present study, partly reported elsewhere in French (Nalpas et al., 2016), we draw upon data from a community research project with self-help groups for people with alcohol problems to analyse abstinence for 12 months after alcohol cessation in patients who are members of these associations, with or without medical follow-up.

PARTICIPANTS AND METHOD

The study protocol was developed jointly by researchers and repre-sentatives of the six self-help associations which constituted the Inserm Alcohol Group at time of the study. By using this method, the protocol therefore met the criteria of community research. The six participating members were, in alphabetical order: Alcooliques Anonymes (http://www.alcooliques-anonymes.fr/); Alcool Assistance (https://www.alcoolassistance.net/); Alcool Ecoute Joie et Santé (http://www.alcoolecoute.com/); Amis de la Santé (http://www. lesamisdelasante.org/); Croix Bleue (www.croixbleue.fr); and Vie Libre (http://www.vielibre.org). All these associations operate at a national level.

Participants

The inclusion criteria were as follows: man or woman aged at least 18 years; new member of one of the participating associations, or an

existing member who had no contact with the organization for at least 1 year; complete withdrawal from alcohol for <3 months; agreement to provide a personal telephone number for the purposes of the study participation; consent to participate.

Method

The initial evaluation and the follow-up questionnaire were drawn up with, and evaluated by, the participating self-help organizations. Local representatives, appointed by their respective associations and designated accompanying representatives, were responsible for the recruitment of subjects. Participation in the project was suggested to all people meeting the inclusion criteria, within a maximum of 2 months following their ﬁrst contact with the association. The accompanying representative was responsible for collecting initial assessment data: age, sex, relationship status (single/ in a couple), employment status (stable/ unstable/ none), socio-professional back-ground and alcoholism data. These latter comprised: exact duration of abstinence at the time of inclusion in the study; number of stays in a rehabilitation unit; most recent withdrawal method (self-help group only, outpatient medical help, or hospitalization); time at which self-help organization was contacted (before, during or after withdrawal); intensity of craving on a scale of 0 (no desire) to 10 (maximum desire); and whether the patient was receiving specialized medical and/or psychological care for their alcohol problem.

Follow-up each participant was contacted by telephone every 3 months for 1 year (four evaluations), by an investigator experienced in this type of survey, who administered the follow-up question-naire. The questionnaire assessed alcohol status, relationship with self-help group and medical–psychological support. The first ques-tion established whether abstinence had been maintained since the previous evaluation. If the answer was ‘no’, a further set of ques-tions assessed the number of units (i.e. 10 g of pure alcohol) and fre-quency of consumption. A‘lapse’ was defined as an isolated episode of alcohol consumption since the previous evaluation, while a ‘relapse’ was recorded in cases of repeated alcohol consumption. Average weekly consumption was calculated by multiplying the mean number of units per occasion by the weekly frequency, with high-risk intake being defined as a weekly intake of more than 14 units in women and 21 in men. The participant, whatever his alco-hol status, was asked to evaluate his craving score on a virtual ana-logic scale ranging from 0 (no craving) to 10 (severe craving). The relationship with the association, the second area explored, was assessed by attendance at meetings and the number of communica-tions with the group. To evaluate medical–psychological support, participants were asked whether they had been seen by a doctor (family doctor, alcohol specialist, psychiatrist or other specialist) and/or psychologist for their alcohol problem in the past 3 months.

Assessment criteria

The primary outcome measure was a break in abstinence deﬁned by at least one alcoholic drink during the 3 months preceding the assessment. If the exact date of theﬁrst drink was not established, it was recorded as the date of evaluation. Subjects who resumed alco-hol consumption remained in the study and continued to be evalu-ated until month 12.

Statistical analysis

Mean and standard deviation were used to describe quantitative vari-ables, and frequency to describe qualitative variables. Quantitative

90 Alcohol and Alcoholism, 2018, Vol. 53, No. 1

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data were compared using the Student t-test or Wilcoxon test (for nor-mally or non-nornor-mally distributed data, respectively). Qualitative data were compared using the chi-squared test. The Kaplan–Meier method was used to analyse occurrence of relapse as a function of time and the obtained curves were compared using the log-rank test. P< 0.05 was considered signiﬁcant. All analysis was carried out using SPSS V23 (IBM-SPSS Inc, Armonk, NY, USA).

RESULTS

Descriptive characteristics

A total of 145 subjects were recruited. Their main characteristics are presented in Table 1. There were 74 men (59%) and 59 women, aged 47± 9.7 years. Slightly more than half (57%) lived alone, and 51% had stable employment. Withdrawal was performed alone, with medical support or with hospitalization in 30.3, 20.7 and 49% of cases, respectively. Two-thirds of those included had a history of at least one previous stay in a rehabilitation centre. Most partici-pants contacted the self-help organization before alcohol cessation (45.0%). The median craving intensity score was 2 (75th percentile= 4.2). Two-thirds (67.2%) reported receiving medical or psychological support for their alcohol problem.

Drop-out

Of the 145 subjects, 26 were lost to follow-up after inclusion. Analysing the profile of these 26 showed they were slightly but sig-nificantly younger than the others (44.7 ± 11.3 vs. 47.8 ± 9.3, P < 0.01) and had a higher craving score at inclusion, close to the signi fi-cant limit (3.5± 2.8 vs. 2.4 ± 2.5, P = 0.06). The remaining 119 were evaluated at least once. The number of subjects at each stage of the study decreased regularly: 73.8, 64.1, 51.7 and 49% at months 3, 6, 9 and 12, respectively. Overall, 74 (62.2%) of the 119 subjects responded to at least three of the four scheduled evalua-tions, while the others missed one or two at varying times for vari-ous reasons (e.g. changing jobs, moving hvari-ouse). However, in most cases these people informed the investigators in advance of their unavailability and expressed their willingness to remain in the study.

Participation in self-help meetings

Throughout the observation period, attendance at self-help meetings remained high, with more than 80% of subjects attending meetings in each assessment period (Table2). Furthermore, individual attend-ance was rated as high (>20 meetings between two evaluations) or medium (5–20 meetings) by nearly 80% of respondents.

Lapses and relapse

All relapse, defined as the consumption of at least one drink, was analysed using survival curves in the 119 participants who could be contacted at least once during follow-up (Figure 1). Sixty-four (53.8%) had consumed alcohol; of these, 43 cases were classified as relapses and 21 (32.8%) as lapses. Thirty-six of the participants who had consumed alcohol (56.2%) did so in thefirst 3 months and 21 (32.8%) in the next 3 months, meaning a total of 89% of all relapses occurred during thefirst 6 months. At the fourth evaluation (month 12), the rate of strict abstinence was 0.43, compared to a full relapse rate of 0.58. The rate of lapse which corresponded to the difference between the abstinence and the relapse rate was 0.15.

The survival curve method requires that any subject in whom the event (in this case, any break in abstinence) occurred is no longer counted in the rest of the analysis until the end of the observation period. However, even if an individual consumes 1 or more units, they may later return to abstinence during follow-up. Here, because the participants who relapsed remained in the study, we were able to select the 47 who said they had drunk at one assessment, but not the previous one. At the next assessment, 18 (38.3%) of these declared that they had become strictly abstinent, and 29 (61.7%) were still drinking alcohol, either having lapsed or relapsed.

Craving

At each assessment, the craving reported by the patients was signi ﬁ-cantly higher (P < 0.01) in those who had consumed at least one drink than in those who had remained abstinent (Table 3). The score did not differ between those who had consumed alcohol once and those who were consuming it regularly (results not shown).

Factors associated with lapse or relapse

The proportion of participants who had consumed alcohol did not differ according to gender (54.3% of men vs. 53.1% of women; NS), method of withdrawal (62.2% of those who withdrew from alcohol without help vs. 50% of those who had medical help; NS), history of one of more stays in a rehabilitation unit, or the time of contact with the self-help association (before, during or after withdrawal). However, the craving score at the initial assessment (month 0) was signiﬁcantly higher in those who had consumed alcohol at month 3 than in those who had not (3.1± 2.7 vs. 2.0 ± 2.4, respectively; P = 0.02). One year after cessation of alcohol, participants who had received medical and/ or psychological help had signiﬁcantly lower rates of strict abstinence and of absence of relapse than those who had not (0.58 vs. 0.35, P= 0.006; 0.77 vs. 0.49, P= 0.001) (Fig.2) despite similar attendance at group meetings.

DISCUSSION

This study focuses on a population that is poorly understood, at least in France: those who seek help from self-help organizations for people with alcohol problems. This population is rarely recorded or Table 1. Descriptive characteristics of study participants

N 145 Men/women 74/59 Age, mean± SD 47± 9 Living alone (%) 57.0 Professional status (%) Working 51.0 Unemployed 49.0 Withdrawal method (%) Alone 30.3 Inpatient 49.0 Outpatient 20.7

Craving score, median [range] 2.0 [0–10] History of rehab. unit stay (%) 64.8 Contact with self-help organization

Before withdrawal 45.0

During withdrawal period 23.9 After withdrawal period 31.0 Medical and/or psychiatric follow-up 67.2

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taken into account in clinical trials for the treatment of alcohol dependence.

However, the cohort of patients in the present study is not repre-sentative of the whole population of those experiencing difﬁculties with alcohol and, as such, the study has limitations worth noting.

We used a so-called convenience sample that meet a set of prede-ﬁned inclusion criteria. As with our study poor follow-up rate is characteristic of studies in people with addiction (Kranzler et al., 1996). However, with only a quarter of our participants lost to follow-up at month 3, and half at month 12, the present study had a relatively high follow-up rate compared with that reported in the lit-erature, which estimates the rate of loss to follow-up as 40% by month 3 (Kranzler et al., 1996). Recommendations have recently been made to try to improve retention in trials (Witkiewitz et al., 2015).

Our results are based on regular quarterly follow-up. They are consistent with others (Mueller et al., 2007), which report that almost all relapse occurs during thefirst 6 months of alcohol cessa-tion. However, there is uncertainty about the notion of relapse and its duration over time. Indeed, our study, in which all included parti-cipants were followed up throughout the entire duration of the investigation, even if they had consumed alcohol, revealed that in almost 40% of cases, there is a return to abstinence within 3 months of the relapse. Consequently, the recent European Medicines Agency directive, which recommended an evaluation at the sixth month of follow-up instead of the third (http://www.ema.europa.eu/docs/en_ GB/document_library/Scientific_guideline/2010/03/WC500074898. pdf), could still be insufficient and should be extended to 12 months.

The rate of strict abstinence at 12 months is comparable to the ﬁndings of a similar study conducted in the United States in 2001 (Humphreys & Moos, 2001), and is slightly higher than that found in a German study in 2007 (Mueller et al., 2007). If only full relapse (rather than lapses) is considered to compromise the patient’s stabil-ity then, at 12 months, nearly 6 out of 10 participants could be con-sidered stabilized.

Craving has long been identiﬁed as a prognostic factor for relapse (Mathew et al., 1979). Here, the mean craving score upon entry into the study was low, but it was higher among those who then consumed alcohol at the month 3 evaluation. Over time, the score decreased in those who continued to abstain, perhaps related to increasing disinterest and/or forgetting of the product.

Although the alcohol consumption history, withdrawal method, and time of first meeting with the self-help group were not asso-ciated with relapse, patients who received specific medical or psy-chological support for their alcohol problem, in addition to group support, had much worse outcomes, whether in terms of a lapse in strict abstinence or a full relapse. However, there is no evidence to suggest that medical and/or psychological monitoring would be dele-terious; it may simply be that the existence of specialist support indi-cates a particularly severe alcoholic illness and/or co-occurring diagnosis. Although we cannot test this hypothesis in the absence of the necessary data, if it is true, this would mean that in subjects with Table 2. Self-help group attendance. (Individual attendance high: more than 20 meetings between two evaluations; medium: 5_–20 meet-ings; poor: less than_{five meetings)}

Evaluation date Respondents (N) Subjects attending meetings (%) Individual attendance at meetings (%)

High Medium Poor

Month 3 103a _93.2 _49.5 _33.7 _16.8

Month 6 88b _84.1 _62.2 _25.7 _12.1

Month 9 75 86.7 60.9 23.4 15.7

Month 12 71 80.3 43.1 36.2 20.7

a_{Four and}b_{seven subjects did not answer this question.}

Fig. 1. Rates of abstinence and relapse over time.

Table 3. Craving score as a function of time and alcohol consump-tion. (Alcohol_{+ denotes patients who resumed drinking at time of} assessment. Craving score were compared using the Wilcoxon test)

Assessment Alcohol status Craving score P (number of

participants)

(mean± SD) Alcohol+ Alcohol− Alcohol+ Alcohol−

Month 3a ₄₂ ₆₁ _1.5_{± 1.8} _3.3_{± 3.2} _<0.001 Month 6b ₃₆ ₅₂ _1.6_{± 2.0} _3.4_{± 2.8} _0.01 Month 9 20 55 1.0± 1.2 2.8± 3.0 0.03 Month 12 26 45 1.1± 1.6 2.3± 2.7 0.05

a_{Four and}b_{seven participants did not answer this question.}

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a mild alcohol problem, participation in self-help meetings would be sufﬁcient to maintain abstinence. Attendance in a self-help group would reduce the need for medical treatment and thus reduce treat-ment costs, as suggested by other authors (Humphreys & Moos, 2001;Humphreys & Moos, 2007).

Another explanation for this elevated risk of relapse could be a conﬂict between the messages delivered by the associations (absolute abstinence) and healthcare specialists (risk reduction) as possible outcomes, the latter implicitly authorizing the individual to maintain a level of consumption. As long as consumption remains very low, the probability of a full relapse is low; conversely, higher consump-tion is associated with uncertain outcomes. Because those opting for risk reduction in the present study constituted only a small sub-group, their results must be interpreted with caution, but it would be pertinent to analyse in more detail the long-term outcomes in such individuals.

Results from studies investigating the impact of participation in a self-help group on maintaining abstinence have been contradic-tory, with some reporting no benefit (Timko et al., 2000;Gossop et al., 2007; Mueller et al., 2007) and others the opposite (Humphreys & Moos, 2001;Ye & Kaskutas, 2009). Such discrep-ancies could arise, among other reasons, from a lack of consider-ation of the severity of illness, as well as from the frequency of participation in meetings. Indeed, in a study conducted in the United States, the abstinence rate 5 years after joining a self-help group was much higher among those with a good attendance record (Kaskutas et al., 2005). This variable could not be studied reliably in our sur-vey because the small number of subjects with poor attendance did not allow a comparative analysis with a sufficient degree of confidence.

In conclusion, one of the most salient elements of the present study is that the data highlight the need for a fresh look at research practices in alcoholism research. The involvement of self-help

organizations in the design and implementation of the study was a success. The accompanying representatives invested a great deal in the tasks entrusted to them, as evidenced by the results and the retention rate. Furthermore, a new profile of subjects in need of assistance emerged: those who benefited only from the help of the group, without medical support, and maintained cessation of all consumption. This group falls outside the‘classical’ healthcare path-ways; it is therefore poorly understood and deserves to be explored further. The present study can be considered as having had a dual impact for self-help organizations: scientific, because beyond their role as activists, it has been demonstrated that such groups can con-tribute valid research data; and political, because they are able to claim a place in the healthcare system alongside established treat-ment programmes, having demonstrated their effectiveness with people for whom they are the only source of support.

ACKNOWLEDGEMENTS

The authors thank Mrs Florence Lafay-Dufour from the ‘Mission Interministérielle de Lutte contre les Drogues et les Conduites Addictives’ for her support; Mrs Magali Desforges for technical and logistical assistance; and all of the accompanying representatives of the self-help associations for their commitment to the study.

FUNDING

This work was supported by the Mission Interministérielle de Lutte contre les Drogues et les Conduites Addictives, Paris, France (Convention Montpellier III, 2013).

CONFLICT OF INTEREST STATEMENT

The authors declare no conﬂicts of interest.

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