Professional treatment plays a vital role in helping individuals with alcohol use disorder (AUD) stabilize and begin recovery. Typically, however, some form of ongoing support is needed to increase the chances of stable remission. Consequently, a common clinical strategy is to link patients with freely available mutual-help organizations (MHOs), which can provide flexible ongoing community-based support. MHO effectiveness and cost-effectiveness have been supported empirically and, consequently, referral to MHOs is recommended in most practice guidelines. A limitation of the current standard of care, however, stemming from a lack of data, is the fact that referrals are typically made almost exclusively to spiritually-oriented 12-step organizations, such as Alcoholics Anonymous (AA). One important consequence of this virtual predominance of studies on 12-step MHOs is that they are the only empirically-supported MHO continuing care referral option. Given the spiritual orientation of 12-step organizations, however, and rulings by some US states? supreme courts that 12-step MHOs are technically religions and thus cannot be the sole referral option, it is important to offer secular alternatives. One prime candidate is SMART Recovery, a secular cognitive-behavioral MHO providing peer support in 1,200 face-to-face meetings in the US. Little is known, however, regarding its real-world benefit. A rigorous study showing SMART Recovery can help reduce relapse risk would provide valuable information that could boost clinical confidence in SMART as a low-cost recovery resource and thus be a secular empirically- supported clinical referral option. As a next step in evaluating the real-world clinical and public health utility of SMART Recovery, the current study will: 1. Characterize and describe professional and non-professional recovery support service participation choices, migrations, and pathways using group trajectory analyses over a two-year period for individuals (N=348) starting a new AUD recovery attempt. 2. Investigate the comparative effectiveness of SMART Recovery by comparing outcomes of AUD individuals making the new recovery attempt (N=348) pursuing either a SMART Recovery (n=174), or a non-SMART recovery (n=174), pathway. Because roughly half of SMART participants also choose to attend AA, we will use a stratified design to enroll persons with AUD making naturally occurring continuing care choices vis--vis participation in MHOs in a balanced fashion, and follow them prospectively across a 2-year period (i.e., SMART + AA vs. SMART-Only vs. AA-Only vs. Neither). Because prior data shows SMART participants may be less severe than AA participants, we will stratify groups by AUD severity (mild, moderate, and severe). In addition to using propensity score matching, this stratification will allow us to compare with greater scientific rigor the outcomes of persons choosing to participate in SMART Recovery vs. not, while accounting for simultaneous choices regarding AA or no MHO participation. 3. Explore mechanisms of behavior change (e.g., self-efficacy, impulsivity), as well as moderators of the degree of benefit (e.g., gender, psychiatric distress) to help determine how SMART Recovery may help its affiliates.

Public Health Relevance

Alcohol use disorders (AUDs) are among our most prevalent and intransigent public health conditions and, while treatable, often require continuing recovery support to maximize the likelihood of stable remission. Clinical referral to freely available mutual help organizations (MHOs) are empirically supported, though the evidence is limited to studies on 12-step MHOs. Given the spiritual emphasis of 12-step MHOs and recent US states? supreme court rulings that 12-step options are technically religions and cannot be the sole referral option, a scientific understanding of secular MHO alternatives has become increasingly more critical. SMART Recovery is the largest secular MHO, but little research has been conducted to evaluate its clinical and public health utility limiting evidence-based clinician referral options. Through a comparative, balanced, prospective research design, this study will provide preliminary real-world estimates of the benefit conferred by SMART Recovery participation.

National Institute of Health (NIH)
National Institute on Alcohol Abuse and Alcoholism (NIAAA)
Research Project (R01)
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National Institute on Alcohol Abuse and Alcoholism Initial Review Group (AA)
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Hagman, Brett Thomas
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Massachusetts General Hospital
United States
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