substance abuse research and treatment

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• April 01, 2024 | VOL. 181, NO. 4 CURRENT ISSUE pp.255-346
• March 01, 2024 | VOL. 181, NO. 3 pp.171-254
• February 01, 2024 | VOL. 181, NO. 2 pp.83-170
• January 01, 2024 | VOL. 181, NO. 1 pp.1-82

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Personalizing the Treatment of Substance Use Disorders

• Nora D. Volkow , M.D.

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The opioid crisis in the United States has brought drug addiction to the forefront of the public mind and to the attention of health care personnel, organizations, and agencies. The epidemic of overdoses, beginning with those caused by prescription opioid analgesics and then broadening to include heroin and fentanyl and its analogs, has prompted major initiatives in local communities, states, and at the federal level to treat addiction and pain more effectively. The crisis has highlighted an insulated addiction treatment system that for decades was segregated from the rest of health care because of stigma associated with addiction and, by extension, the medications used to treat it. Stigmatizing attitudes have been slow to erode, but the moralizing and punitive viewpoints of the past are gradually giving way to a medical and even a cultural consensus that addiction is a chronic disorder of the brain, one that is strongly influenced by social factors, and one that is also treatable.

Parallel research in animal models and brain-imaging studies in individuals with substance use disorders has given us an increasingly precise picture of their neurobiology, including molecular and synaptic changes and the neuronal circuits involved, along with the consequences of their disruption. Most people are exposed to addictive substances at some point in their lives, including alcohol and nicotine, and many use these substances recreationally without developing addiction. Similarly, many patients who use opioids to treat their pain don’t develop addiction. But in a subset of individuals who are vulnerable because of genetics, age, and other variables, repeated exposure to addictive drugs diminishes the capacity of basal ganglia circuits to respond to natural reward and to motivate the behaviors needed for survival and well-being, while enhancing the sensitivity of stress and emotional circuits, including those from the extended amygdala, triggering anxiety and dysphoria when not taking the drug and weakening prefrontal executive-control circuitry necessary for self-regulation ( 1 ).

These changes, along with learning mechanisms that tie expectation of reward to drug cues, intensify each other in a kind of perfect storm: Inability to feel reward from non-drug activities, including social interactions, takes away the enjoyment of life and increases social isolation. Intense symptoms of withdrawal drive a search for temporary relief, and constant reminders of the drug in the environment contribute to persistent craving and preoccupation with obtaining the drug. Weakened capacity to resist the urge to take the drug or follow through on resolutions to quit leads, very often, to relapse and the accompanying regret or shame at having failed. Further increasing relapse risk are the frequently associated symptoms of depression, anxiety, and impaired sleep.

Until recently, the development of treatments for addiction was aimed at bringing about cessation of drug consumption (abstinence), which was the outcome required for U.S. Food and Drug Administration (FDA) approval of medications for substance use disorders. However, our current understanding of the mechanistic processes underlying addiction identifies a much broader set of clinically beneficial outcomes. For example, reduction of use in a person who uses heroin could decrease his or her risk of overdose, and improvements in sleep, depression, or executive function could also reduce relapse risk. In addition, technological advances and our growing understanding of the underlying neurobiology have given us the opportunity to target discrete neurobiological processes and personalize interventions to the unique deficits in a given individual and across the course of an individual’s disorder. A dimensional, personalized, and dynamic approach to treating substance use disorders could draw from medication use, neuromodulation techniques, behavioral approaches, and their combinations as the individual moves toward recovery.

Alternative Endpoints

To achieve a dimensional approach to treatment requires thinking anew about how we develop new treatments and what we expect in a treatment.

The existing pharmacopoeia for substance use disorders is severely limited. The FDA has approved medications only for alcohol, nicotine, and opioid use disorders ( Table 1 ), and currently there are no approved medications for cannabis, cocaine, methamphetamine, or inhalant use disorders. The absence of medications to treat most substance use disorders and the limited number of existing medications for alcohol, nicotine, and opioid use disorders make development of new therapeutics a high priority. Yet drug development for substance use disorders faces great hurdles.

a AMPA=α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid; FDA=U.S. Food and Drug Administration; GABA=γ-aminobutyric acid; NMDA= N -methyl- d -aspartate.

TABLE 1. Drugs approved by the FDA for treatment of substance use disorders a

To obtain FDA approval for most substance use disorders, medications until recently had to demonstrate that they produce abstinence in a significant subset of patients, as measured by negative urine tests. However, the abstinence endpoint is a high bar to achieve, equivalent to requiring remission of pain from an analgesic or remission of depression from an antidepressant. Yet, the FDA granted approval of analgesics and antidepressants on the basis of reduction of symptom severity, not remission ( 2 ). The high bar for addiction medications has discouraged investment by the pharmaceutical industry, and significant public sector help was required to bring many of the currently available medications for substance use disorders to market, including buprenorphine, extended-release naltrexone, lofexidine, and naloxone nasal spray.

Treatment programs for substance use disorders inherited a dichotomous working definition of recovery from the 12-step world of past generations, where being completely “drug free” was not merely the gold standard but the only standard, short of which an addicted individual was regarded as having failed or would not be considered to be “recovering.” Yet evidence indicates that abstinence is not the only clinically relevant outcome for every individual and that alternative endpoints can contribute to recovery even when abstinence is not completely achieved.

Reduced alcohol use (measured as percentage of heavy drinking days) is now being used as an endpoint in clinical trials for treatments for alcohol use disorder. The FDA has also recently expressed its openness to considering endpoints other than abstinence as targets in medication development for other substance use disorders ( 3 , 4 ). Given the illegality of many addictive drugs, it has been argued that any reduction in use should be considered a benefit to the individual’s health and safety ( 5 ). Every time a person addicted to heroin must obtain the drug, he or she faces the risks associated with the drug trade as well as with exposure to fentanyl or a contaminant that could lead to overdose or poisoning.

Recently, researchers found in a pooled sample of study participants with cocaine use disorder that those who had high-frequency use at the start of the study and had reduced to low-frequency use by the end of the study showed outcomes at 1-year follow-up similar to those of participants who had quit altogether ( 6 ).

Treating the Dimensions of Substance Use Disorder

Endpoints other than abstinence may lead not only to treatments that are helpful in reducing drug use but also to the use of compounds that target specific neurobiological processes and symptoms relevant to addiction and the risk for relapse.

In April 2018, the FDA, in partnership with the Addiction Policy Forum and the National Institute on Drug Abuse (NIDA), convened a meeting to solicit input from patients with opioid use disorder as part of its Patient-Focused Drug Development initiative ( 7 ). Among other things, participants emphasized their desire for a more holistic and individualized approach to treatment, as well as their wish for medications that would address specific symptoms of withdrawal, such as cravings, depression, cognitive impairments, pain, and sleep problems. The same year, the FDA approved lofexidine for treating physical symptoms of opioid withdrawal during detoxification—the first approved drug for treating symptoms associated with opioid use disorder with a restricted purpose and not expected to lead, by itself, to continued abstinence. After detoxification, the individual would ideally be treated with naltrexone or buprenorphine as a longer-term treatment to help prevent relapse and achieve recovery. Other potential targets for medications are those that, while not addressing addiction directly, target major risk factors for relapse.

One such factor is insomnia, for it is frequently interrelated with substance use disorders, with each exacerbating the risk of the other. Findings of shared targets and circuits between disrupted sleep and addiction offer unique opportunities for treatment development. For example, while studying the role of orexin in narcolepsy, researchers serendipitously discovered an unusually high number of orexin-producing neurons in the postmortem brain of a heroin-addicted individual ( 8 ). They subsequently established in preclinical models and postmortem brain studies that long-term use of heroin was associated with an increase in orexin-producing neurons. Since orexin is already targeted by suvorexant, an FDA-approved drug for insomnia, NIDA is funding research to test its efficacy, along with that of other novel orexin receptor antagonists, as therapeutic agents in opioid use disorder.

Similarly, dysphoria and depression, which are frequently associated with protracted withdrawal, are another relevant area where our growing understanding of underlying neurocircuitry could guide selection of promising new targets. For example, the habenular complex is intricately involved in dysphoria and negative emotional states and is associated with depression ( 9 ) and addiction ( 10 ). Both alpha-5 nicotinic acetylcholine receptors and mu-opioid receptors are highly expressed in the habenula, where they modulate its activity, contributing to the adverse symptoms of withdrawal that follow nicotine and heroin discontinuation, respectively, and to the relief that follows during intoxication. Targeting the habenula has already been shown to be beneficial in animal models of addiction treatment ( 11 ), and it has been a target for deep brain stimulation for the treatment of depression ( 12 ).

Because of the high comorbidity of substance use disorder with depression, psychiatrists have used antidepressants off-label to treat their addicted patients, even though randomized clinical trials of antidepressants have failed to achieve the desired outcome of abstinence. Recognizing that improving depression could still be beneficial for patients with substance use disorders, studies should revisit the possible efficacy of antidepressants as an element of addiction treatment, using endpoints other than abstinence. Bupropion, which blocks the dopamine and norepinephrine transporters and is an approved antidepressant medication, is also approved for the treatment of nicotine addiction. Given the involvement of the mu-opioid receptor system in mood, it would be expected that targeting depression might have particular value in treating opioid use disorder; an interesting feature of the opioid partial agonist buprenorphine is that it has antidepressant properties ( 13 ), and opioid-addicted patients who have depression respond particularly well to this medication ( 14 ).

Another important therapeutic target is that of addressing social isolation, and while this might be optimally achieved with behavioral interventions, including group treatment, medications could still hold promise. Addicted individuals report reduced pleasure from social contact, as well as fear of the stigma attached to their drug use, and thus they tend to isolate themselves. Isolation in turn drives drug taking ( 15 ). Here again, we could take advantage of our increased understanding of the neurobiology of social attachment to bolster social connections. For example, oxytocin, a neurochemical involved in social bonding that also modulates key processes associated with addiction, including reward and stress responses, is being evaluated as a possible addiction treatment and may enhance the efficacy of psychosocial addiction treatments ( 16 , 17 ).

A dimensional approach to the treatment of substance use disorder is also relevant to neuromodulation. Early research has shown that transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) may be useful in reducing drug cravings, and TMS is already an approved therapy for treatment-resistant depression. Research is needed to study how TMS, tDCS, or peripheral nerve stimulation could be used to improve symptoms associated with addiction, from acute symptoms of withdrawal to the more protracted symptoms of dysphoria and sleep problems. As we understand better how to use neuromodulation technologies to modify brain circuits, it may create opportunities to strengthen specific circuits that can buffer or compensate for others that have been impaired by drug use or constitute a predisposing vulnerability.

Behavioral therapies are also suited to dimensional approaches to substance use disorder treatment. Considerable research already shows the benefits of cognitive-behavioral treatments in improving self-regulation and of contingency management in strengthening the degraded motivation to engage in non-drug-related activities, so clearly these modalities are effective for addressing specific dimensions of the addiction process. Similarly, behavioral treatments to improve executive function could help build resilience against relapse, as shown by methylphenidate’s reported ability to reduce impulsivity in individuals with cocaine use disorder ( 18 ).

Making Addiction Treatment More Dynamic and Personalized

Trajectories of use vary among people who use drugs, ranging from persistent use or declining use to cessation and relapse or sustained cessation. Studies of people who inject opioids, for example, have identified factors that, to some extent, are predictive of these trajectories ( 19 ). Being in a stable relationship, for instance, has been associated with early cessation (highlighting the importance of social support).

Addiction is an evolving disorder that changes through time and across the lifespan of the individual and one that has an unpredictable element that springs from the unique experiences an individual is exposed to. Some widely used behavioral treatments already accommodate and address this changeability of substance use disorder. Cognitive-behavioral therapy teaches the individual to identify external triggers and respond more appropriately to internal states (e.g., mood, craving) that place them at risk for relapse. New technologies are developing algorithms to identify indicators of relapse risk and incorporating them into wearable devices and smartphones with the goal of delivering an intervention in a timely, targeted manner. In the future, as big-data analytics and machine-learning algorithms yield more insight into behavioral and biological markers of relapse risk, tools or devices to avert relapse farther in advance may be developed.

Toward the Future

Neuroscience has revealed that addiction involves a set of interconnected processes that can be targeted strategically, rather than being a disorder defined principally by a single behavior (uncontrollable excessive drug use). Addiction medicine is also increasingly recognizing that factors traditionally associated with recovery are components of treatment. For example, for any meaningful recovery to occur, the individual must be able to integrate him- or herself into a socially meaningful environment. People with substance use disorders who are professionally active or engage in meaningful activity and have a caring family face less of a challenge than those who have no social supports and whose isolation places them at high risk for relapse. The integration of peer mentors, recovery coaching, and supportive housing into addiction treatment is an example of this shift, but more research is needed to determine the most effective ways to sustain social inclusion and to achieve recovery ( 20 ).

Addiction is a complex disorder that involves brain circuits necessary for survival and one that is strongly influenced by genes, development, and social factors. We now understand the underlying mechanisms well enough that we can turn this complexity into an opportunity to include these dimensions as targets for substance use disorder treatment, as well as to personalize interventions to accommodate the unique neurobiological characteristics and social contexts of individual patients.

Dr. Volkow is Director of the National Institute on Drug Abuse.

The author thanks Eric M. Wargo and Emily B. Einstein for their valuable help in the preparation of this article.

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• Opioid Use Disorder
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The Twelve Steps and Adolescent Recovery: A Concise Review

Recovery and long-term remission are the goals of treatment for substance use disorders, yet the majority of treated adolescents never stop using or resume using substances quickly after treatment. Thus, continuing care or recovery support services are common post-treatment recommendations for this group. Almost half of people who resolved significant substance use problems did so through participation in 12-step programs like Alcoholics Anonymous or Narcotics Anonymous. These recovery support programs are available online and in communities around the world. Yet <2% of these programs’ members are under 21 years old. To help clinicians understand the 12-step explanatory model and facilitate clinical decision making on whether or when to refer individuals to these groups, this article summarizes the 12-step philosophy and practices and provides a concise review of research on adolescents’ involvement in 12-step groups, including qualitative work that illuminates adolescents’ reasons for resisting or engaging in 12-step practices.

Introduction

In 2016, about 1.1 million American adolescents needed treatment for a substance use disorder (SUD). 1 – 6 Adolescents with heavy use of alcohol and/or marijuana perform more poorly than non-using controls on tasks involving psychomotor speed, memory, attention, and cognitive control. 7 Because their brains are undergoing rapid development, adolescents with untreated or undertreated SUDs are at risk for developing chronic addiction. 8 , 9 A variety of psychosocial treatments exist for treating adolescents with SUD. Treatments with the most empirical support include family-based approaches, motivational enhancement (MET), contingency management, cognitive behavioral therapy (CBT), and 12-step facilitation. 10 , 11 Most programs provide a combination of approaches. 8 Completing any evidence-based treatment is better than no treatment and results in reductions in substance use. 8 , 12 The goals of adolescent SUD treatment are remission and long-term recovery, 13 yet the majority of treated adolescents never stop using or resume using substances quickly after leaving treatment. 12 , 14 Thus, it is common practice to recommend continuing care or recovery support services that provide ongoing motivation and social support for sobriety to extend the benefits of SUD treatment. 4 , 12 One in ten Americans report having resolved a significant problem with alcohol or other drugs (AODs). 15 Though there are many pathways to recovery, approximately 45% report resolving their problem through participation in 12-step programs. 15 Thus, 12-step programs are widely recommended for adolescents as an adjunct to professional treatment services. 16 , 17 To facilitate clinical decision making on whether or when to refer individuals to these groups, this article summarizes the 12-step philosophy and practices and provides a review of research on adolescents’ involvement in 12-step groups.

Twelve-step philosophy and practices

An understanding of 12-step philosophy and practices may help clinicians determine which of their adolescent clients may benefit from referral to these programs. Twelve-step programs are the most commonly sought resources for people with AOD problems. 18 Their program for recovery is represented by the 12 steps ( Table 1 ). 19 A variety of 12-step programs exist for people who struggle with addiction and their families (eg, Cocaine Anonymous, Marijuana Anonymous, Gamblers Anonymous, Al-Anon, Alateen, etc.), but the oldest and most readily available are Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). All 12-step programs emerged from AA, which has been in existence for more than 80 years. 18 , 20 Twelve step programs are one source of recovery capital (the collective resources an individual can access to support their recovery from SUD). 21 , 22 These community-based recovery support programs are peer-led, non-professional fellowships whose primary purpose is mutual help. 18 , 23 – 25 Together, AA and NA claim to have helped millions of people recover from AOD use problems. 13 , 14 In 1951, AA received the prestigious Lasker Award from the American Public Health Association “in recognition of its unique and highly successful approach.” 26 AA’s sentinel text states, “AA is a fellowship of men and women who share their experience, strength, and hope with each other that they may solve their common problem and help others to recover from alcoholism” (p.xxiv). 19 , 27 Twelve-step programs are free of cost and are available in 180 countries and more than 65 000 cities in the U.S and Canada. 18 , 25 For those who lack access to in-person meetings, there are hundreds of online meetings or chatrooms. 28 Moreover 12-step focused social network platforms like Facebook™ and Reddit™ provide individuals access to support any time of the day or night. 29 , 30

The twelve steps of alcoholics anonymous. 1

Note: Adolescents substitute the word “alcohol” with whatever substance they personally struggle with.

Positing that people with addiction have lost the ability to control their substance use, the 12-step philosophy defines recovery as abstinence from AODs and includes the personality changes and spiritual growth that result from practicing the 12 steps and assimilating the 12-step principles (eg, integrity, courage, hope, other-focus) into one’s value system. 27 , 31 Twelve-step programs are not affiliated with any political or religious organizations, and they do not require any particular belief system, but they do teach that spiritual experiences are the means by which changes that support recovery occur. 16 , 23 , 24 People are encouraged to take personal responsibility for their behavior, read 12-step literature, attend 12-step meetings, abstain from the use of substances one day at a time, find a sponsor (a person in recovery who has worked the 12 steps) to guide them through the program, give of themselves in service, and develop a spiritual connection that makes sense to them. 27 , 31 , 32 The emphasis of 12-step meetings is sharing recovery narratives. Sharing reduces members’ sense of isolation, teaches practical skills for living a substance free life, and produces hope and a sense of belonging. 33 , 34

Adults and the 12 steps

A wide body of research demonstrates that 12-step groups help adults recover by mobilizing therapeutic processes that are similar to professional treatment. 23 – 25 Twelve-step facilitated (TSF) treatment programs blend multiple evidence-based therapeutic elements (eg, CBT, MET, group and family therapy, etc.) with elements of the 12-step philosophy and frequently introduce individuals to community 12-step programs to facilitate transition to this recovery support model after treatment. 6 TSF treatment programs produce as good or better rates of sustained remission than CBT or MET. 35 The primary mechanisms of behavior change for adult 12-step participants are through the internal transformations that result from working through the 12 steps and from fellowship with the recovery community. 33 , 36 , 37 Fellowship refers to the social gatherings and communication between members who teach, model and support recovery skills, values and behaviors. 24 , 20 , 33 , 38 People with severe addiction recover through the same pathways, but they also report improvements in depression through enhanced spiritual practices. 35 – 37

Adolescents and the 12 steps

Fewer studies have been done with adolescents and the 12-steps but evidence suggests 12-step involvement may be a viable option for post-treatment continuing care. 2 , 4 , 5 , 11 , 16 , 60 In the U.S., almost half of adolescent treatment programs require 12-step involvement to some degree during treatment. 5 Adolescents who attend TSF treatment programs have fewer substance use-related consequences and more 12-step involvement after treatment. 4 Treatment programs that do not incorporate the 12-step philosophy or practices typically recommend that individuals attend 12-step or other mutual support groups after treatment to support their ongoing recovery. 6 , 12 , 16 Twelve-step participation is related to improved outcomes and greater recovery capital resources for adolescents both during and after treatment. 6 , 34 , 35 , 39 , 40 More frequent 12-step attendance predicts greater community recovery capital access, such as attending a recovery high school. 39 Adolescents who participate in 12-step programs have significantly more abstinent days and are more likely to remain abstinent than non-attenders. 2 , 41 Adolescents who attend more frequently have better outcomes, and active involvement (working the steps with a sponsor, providing service, etc.) predicts sustained remission better than attendance alone. 4 , 41 A 2010 review of 19 studies reported that 12-step involvement predicted two- to three-fold higher abstinence rates for adolescents. 16

In 2017, Lee et al. found that 12-step involvement facilitated the experience of spiritual love in juvenile offenders mandated to a TSF treatment program. This experience combined with high levels of service to others produced higher levels of humility and was associated with reduced one-year recidivism and relapse rates. 42 Adolescents with severe SUD and those with comorbid psychiatric problems participate in 12-step groups at similar or higher levels and experience comparable or better outcomes than their less severely affected counterparts. 43 , 7 Moreover, 12-step involvement by adolescents has been shown to reduce medical costs over a 7-year period after treatment, with an estimated cost reduction ratio of 4.7% for every 12-step meeting attended. 44 These cost savings were related to reductions in SUD treatment, hospital stays, and mental health provider visits. 44

Though adolescents can attend any 12-step group, groups specifically designed for young people began in the 1940s. Though less available than adult groups, young people’s groups are available in many communities and on-line. 45 , 46 However, despite strong clinical recommendations and the availability of age-appropriate groups, many adolescents never attend 12-step groups, and those who do attend less frequently and drop out sooner than adults. 16 , 43 , 47 Several potential barriers for adolescents’ 12-step participation have been proposed. 47 Adolescents typically have shorter substance use histories and fewer consequences for use, which may result in low problem recognition. Because of adolescents’ developmentally-specific characteristics (limited insight, limit testing, and fewer physical problems related to substance use), they may enjoy getting high and resist the 12-step recommendation for total abstinence. 16 , 49 Their developmental need for autonomy may lead adolescents to resist the 12-step principle of admitting powerlessness. 16 , 49 The average age of AA and NA members is 48 years. 50 , 51 This age disparity may lead adolescents to resist attending because they feel unsafe or unable to relate to the life roles and life experiences of older adults. 16

Though limited, research on adolescent 12-step program participation supports some but not all of the aforementioned proposed barriers. Adolescents of both genders reported feeling safe at 12-step groups, and their reasons for dropping out or not attending were unrelated to safety concerns. 52 , 53 The most common reason adolescents reported for not attending 12-step groups was opposition to the idea that they had a problem or needed help. 54 Other primary reasons reported for not attending or discontinuing 12-step program attendance were logistical barriers (eg, no transportation), relapse, boredom, or lack of fit. 53 , 40 Attending groups with similarly aged peers was found to be related to higher abstinence shortly after treatment but not over time, especially for adolescents who attended more often. This implies that attending groups with similarly aged peers may promote better participation early in recovery, but expanding to groups with older members may benefit adolescents who are further along in recovery. 41 Adolescents in treatment whose parents were familiar with 12-step practices or who had histories of greater lifetime religious practices were found to adopt and practice the 12 steps more readily. 55 This resulted in increased service-related behaviors, reduced cravings, and lower perceived entitlement. 55 Another study reported that practicing the 12-step virtue of service produced humility, fostered recovery, and reduced recidivism in a group of juvenile offenders that scored high on defiance. 42

Adolescents’ perceptions of the 12 steps

Though sparse, qualitative research exploring adolescents’ perceptions of 12-step groups or experience practicing the 12 steps has shed light on the specific barriers and/or benefits to 12-step practices for this group. Studies with adolescents and young adults in treatment with some prior AA or NA experience solicited their reasons for attending (or not) 12-step groups and what they found helpful about these groups. On average, participants felt 12-step groups were helpful to their recovery efforts, although a quarter perceived no benefit from them at all. 40 Both adolescents and young adults valued general group therapy elements more than the 12-step practices. 53 , 54 Aspects of 12-step groups that participants liked most involved social processes, such as being able to identify with and learn from others’ experiences, as these provided encouragement, hope and support for recovery. 53 Gonzales et al. 56 , 57 conducted focus groups with young people ages 12 to 24 who were in treatment. Most of these participants reported opposition to the 12-step philosophies of admitting personal powerlessness over substance use and maintaining lifelong abstinence. Resisting the concept of the need for ongoing treatment or 12-step program participation, these youth believed that the resolution of substance use problems was just a matter of learning coping skills and making better life choices. 56 , 57 These perceptions may reflect the developmental distinctions of adolescence (limited insight, less severe consequences for use, poor problem recognition, and limit testing) that is typical of adolescents in treatment. 8

In contrast to these findings, qualitative work with young adults who previously participated in an alternative peer group (APG) during adolescence revealed that although the social aspects were critical, they considered the process of working through the 12 steps to be the agency for their recovery. 34 The APG is a TSF community-based recovery support model for adolescents. APGs facilitate adolescents’ development of new pro-recovery peer networks by incorporating peer role models and sober recreational activities into professional recovery-support practices such as counseling, family involvement, and case management. 58 These youth reported learning of the 12 steps in the APG but also attending outside groups. The majority of interviewees reported initial ambivalence or resistance to treatment that resolved over time with exposure to peers who had some time in recovery and seemed to be “happy.” Furthermore most reported initial opposition to 12-step philosophies (particularly the spiritual aspects). However, over time with recovery role models they gained insight into their substance-related problems and with encouragement from peers, tried the 12 steps. Once they experienced personal benefits from the 12-steps, they either embraced the spiritual aspects or substituted dependence upon the group as their “higher power.” The combination of social support from the APG and working the 12 steps led to motivation for sobriety and improvements in their mental health symptoms, relationships, and happiness. 34 Most remained involved for extended periods of time (from six months to several years). 34 This study recruited young people who considered themselves to be in recovery, so their perceptions were subject to self-selection bias. Never-the-less, findings of the study suggest involving peer role models may be key to promoting adolescents’ problem recognition and retention in continuing care.

In another study, adolescents who were actively or recently involved in an APG reported mixed perceptions of the 12 steps. 48 , 59 Consistent with prior qualitative work, 56 , 57 low problem recognition, poor motivation for treatment, and stereotypes about 12-step groups were common negative initial perceptions. 48 However, as peers advocated for the benefits and the participants tried working the steps, these initial negative impressions became more positive. 48 After a period of practicing the steps, the personal benefits (eg, reduced cravings, character growth, improved mental health symptoms and quality of life) became primary motivators for continuing 12-step practices. 48 Many participants reported ongoing opposition to the 12-step philosophy of lifelong sobriety, yet they reported practicing the 12 steps “for now,” because they understood the need to protect their developing brains and felt the personal benefits outweighed their reluctance. Moreover, even the participants who were actively using substances and disinterested in recovery reported the 12 steps were beneficial in many areas of life beyond substance use (eg, improved relationships, enhanced self-awareness and self-agency). 48

Resistance to the 12-step philosophy of admitting powerlessness over AOD use and seeking spiritual help has been proposed as a barrier for adolescents because it clashes with adolescents’ developmental need for autonomy or their inclination to test limits. 16 , 41 , 43 When asked about their reasons for attending or discontinuing 12-step groups, adolescents did not list the spiritual focus as a major benefit, nor was it a reason for discontinuing attendance. 40 Other qualitative findings have confirmed that the spiritual focus and admitting powerlessness were significant initial barriers, but consistent with prior research, this resistance was most prominent from those who were just beginning the treatment/recovery process. 48 , 56 , 57 , 34 Adolescents who had actually tried working the 12 steps with recovering peers either found the spiritual aspects of the 12 steps helpful or reported that their personal lack of spiritual beliefs did not prevent them from being able to practice the steps they found to be helpful. 48

Completion of evidence based treatments programs like family therapy, MET, and CBT leads to reductions in adolescents’ substance use. 10 , 61 However, effect sizes are moderate at best and treatment gains fade relatively quickly over time. 12 , 62 Thus, continuing care or recovery support services are commonly recommended to sustain treatment gains. 12 Though not the only model for post-treatment recovery support, research to date suggests that similar to adults, adolescents’ involvement in 12-step groups predicts improved AOD use outcomes, and greater participation (ie, frequency, duration, and extent of involvement) predicts abstinence and SUD remission better than attendance alone. 2 , 4 , 6 , 16 , 41 Moreover, 12-step participation reduces the associated healthcare costs for adolescents with SUD. 44 Despite these benefits, in 2015 <2% of AA’s and NA’s total membership comprised people under 21 years old. 50 , 51 Qualitative research has shed light on adolescents’ reasons for resisting or engaging in 12-step practices and suggests strategies for promoting their involvement. 53 , 56 , 57

To facilitate change in their adolescent clients’ social networks and sustain treatment gains clinicians should explore the continuing care options specifically designed for adolescents in their communities. Recovery high schools 63 , 64 and APGs 58 , 65 are proliferating in communities and may be a more developmentally appropriate option for adolescents because they are professionally directed. If these are not available, research suggests many youth benefit from participation in 12-step groups. A primary strategy clinicians can use to boost adolescents’ motivation for 12-step involvement is to connect adolescents affected by SUD with a community of peers who advocate for the benefits of 12-step involvement. 34 , 48 , 58 , 34 , 48 Youth-focused 12-step groups can be found in many communities, and on-line meetings or social media platforms for young people have increased greatly in the past five years. 28 – 30 , 45 Though research in this area for adolescents is lacking, web-based options may improve access for youth with transportation barriers. Resistance to the 12-step philosophy of life-long sobriety can be addressed by exploring the potential benefits of maintaining sobriety “for now” and involving recovering peers as advocates. Opposition to the spiritual focus can be addressed by relating how other adolescents have been able to benefit from the social support and practical skills gained from 12-step groups without feeling pressured to embrace the spiritual aspects of 12-step philosophy. 48 If available in the community, secular mutual help groups like SMART Recovery may be another option. 65

The findings of this review should be considered in light of its potential limitations, chiefly the relative paucity of research on 12-step groups and adolescents. At the time of this review the majority of available studies were observational or qualitative, with only one small RCT (n = 74). 6 Because adolescents’ likelihood of relapse increases over time, attrition or self-selection may have biased outcomes of longitudinal studies that recruited adolescents while in treatment and monitored them over time. Study samples may have limited generalizability. Most studies were conducted in the U.S. and included primarily Caucasian or Latino participants. The qualitative studies included sample sizes ranging from 12 to 377 and the observational studies included sample sizes ranging from 118 to 403 subjects. Rigorous research studies are needed to examine the short and long-term effects, the mechanisms of behavior change, and predictors of positive or negative outcomes of adolescent 12-step involvement.

This review aimed to enhance clinician’s ability to decide if, how and when to refer their adolescent clients to 12-step programs. Helping adolescents achieve long-term stable recovery from SUD can reduce the negative impact of AOD use on adolescents’ developing brains and limit the personal and societal costs of adult addiction. 7 , 8 Twelve-step programs are the best known and most widely available mutual support programs, and are commonly recommended as an adjunct to professional treatment. 32 Twelve-step groups (particularly those with similar-aged members) provide recovery-supportive social networks to teach and model the recovery skills adolescents need to change from lifestyles that circled around AOD use. Although further research is needed, research to date suggests that 12-step involvement may be a cost-effective option for supporting treatment gains for some adolescents. 60

Acknowledgments

The author is grateful to all the past and present Alternative Peer Group clients, families, and staff who have generously shared their recovery experiences with her since 2011.

Funding: The author received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests: The author declares that there is no conflict of interest.